ARTICLE IN BRIEF:
Neurologists who have been involved with neurology residency training programs question the merits of a trend toward more subspecialist training at the expense of a general neurology background.
When one of the two full-time general neurologists in his Pocatello, ID, practice announced his retirement in 2009, Robert M. Kennedy, MD, PhD, began trying to recruit a clinician to replace him. Nearly ten years later, he's still trying.
“At first, I just thought it was about where we are. Maybe no one wants to come to Idaho?” said Dr. Kennedy. “But the more I talked to people, the more I discovered that there just aren't that many young general neurologists anymore. They're all old folks like me.”
Dr. Kennedy consulted with leaders of the neurology faculty at the University of Utah in Salt Lake City, 150 miles away, where he refers patients who need tertiary-level care. “They told me that more and more residents are going straight into fellowships instead of pursuing a general neurology practice after completing their residencies.”
Indeed, according to an AAN survey published in Neurology in 2016, 88 percent of neurology residents plan to go into a fellowship after residency. The percentage is particularly high for adult neurology residents, 93 percent of whom plan on fellowship training, compared with 56 percent of child neurology residents. General neurology was still the area of practice most often selected as residents' planned area of specialization (25 percent), followed by epilepsy (20.8 percent) and vascular neurology (18.8 percent)—but a number of neurologists, like Dr. Kennedy, are concerned about the trend away from general neurology.
“I've kept track of these numbers, and in previous years the percentage of neurology residents going into fellowships has increased from 75 percent to 80 percent and now to nearly 90 percent overall,” he said.
One promising candidate for the position in Pocatello was a senior resident who grew up in a small town north of Pocatello, who really wanted to return home with his Idaho-born wife to raise a family. “When can you start?” Dr. Kennedy asked him. The young doctor responded that he wanted to pursue a stroke fellowship first. “We asked him why and he couldn't really answer. It was just what you do. So he did that stroke fellowship, and there's only one place in Idaho, in Boise, big enough to support fellowship-trained stroke neurologists. They have one or two there. Doing that fellowship made it difficult for him to make a living here. We just didn't have the demand, so he moved to Kansas City.”
After spending one or two years in subspecialty training on top of years of medical school and residency, fellowship-trained neurologists are often loath to return to general neurology. “They might say when looking for a job that they would be willing to practice general neurology but they usually mean less than 25 percent with the goal go quickly evolve their practice into 100 percent of their subspecialty, as this resident admitted,” Dr. Kennedy said.
Are some neurology residents are getting the message that you can't just complete residency and go into practice without doing a fellowship first? “A friend of mine who teaches part time at the University of Utah was just talking to a third-year resident who is getting panicked because he hasn't gotten a fellowship position yet,” he said. “My friend asked him, ‘Why don't you just practice general neurology?’ The resident said, ‘I can do that?’ He didn't even have an idea that he didn't have to do a fellowship.”
Is there a culture shift underway?
Is the culture of neurology residencies shifting so that it is harder for newly minted graduates to pursue general neurology—or even to think of it as a career possibility? And if so, what is influencing this shift and what, if anything, can or should be done about it?
Some general neurologists say that fellowship training doesn't close off the path to general neurology. Michael E. Markowski, DO, FAAN, is one of six physicians at Neurologists of Cape Cod in Hyannis, MA. One of the six is in his 70s; all of the five other doctors, who completed residency training within this past 15 years, did fellowships before entering general practice.
“Two pursued a neurophysiology fellowship, which includes EMG and EEG training, as residents require more exposure to both tests prior to using in practice,” Dr. Markowski said. “Two others, including myself, completed an EMG/neuromuscular fellowship, for additional EMG training. The fifth is an epilepsy specialist, but is comfortable practicing general neurology. While we all have a subspecialty focus, we feel comfortable practicing general neurology and could definitely have become community neurologists without having done our fellowship training. We enjoy the variety of treating a spectrum of neurologic disease and have very rewarding practices.”
Dr. Markowski said that he did not feel a particular pressure to pursue a subspecialty during his residency training at the University of Massachusetts, having trained with a number of neurologists who practiced general neurology despite having their own chosen subspecialty. “With all the new developments in therapeutics in stroke, headache, multiple sclerosis, and other neurologic diseases, I can see how it's hard to learn all you need to know during residency and how it would be a very daunting task for someone just out of training to hang their own shingle practicing general neurology.”
“I believe the present situation has occurred because the culture of the vast majority of residencies, and their leaders, is to see fellowship is a required step in the training of neurologists. Some are even talking about the necessity of a second fellowship being expected needed,” Dr. Kennedy argues. “And many, if not most, rotations of the three years of neurology residency are inadequate and inappropriate in that they no longer train residents to be able to practice general neurology at the end of their neurology training. Of course, this situation strongly pushes residents into fellowship training also.”
The timeline can be challenging
Some say that the timeline for applying to fellowships puts pressure on neurology residents to make a decision on a subspecialty early on in their post-graduate years. The AAN's own website recommends: “Start early. Check program websites for vacancies and requirements for the application process. Make contact with programs toward the end of your PGY2 year, and no later than October/November of your PGY3 year.”
A schedule that has residents already sorting through fellowship programs in PGY2, and doing their interviews by early in PGY3, contributes to a mindset that residency is just a springboard toward a fellowship, said Susan M. Rubin, MD, interim chair of the department of neurology at NorthShore University HealthSystem and director of the Women's Neurology Center at Glenbrook Hospital in Glenview, IL. “Residencies do still provide a good general neurology background, but because of this schedule in which fellowship decisions are being made early in the third year, residents have to start thinking about what they're going to specialize in before they've developed their skills as general neurologists,” she said.
NorthShore University HealthSystem serves as the primary teaching affiliate for a major medical center, providing them with community-based general neurology and subspecialty experiential rotations. Residents do inpatient consultations as well as rotate through different outpatient clinics, working with various subspecialists.
“We used to do the outpatient rotations in the third year, but we were encouraged by our primary institution to change that to the second year so that the residents could see what was available to them sooner, because they were being asked to make a decision on fellowships earlier,” Dr. Rubin said. “I do think this move has facilitated the residents making decisions on fellowships earlier, but I don't necessarily think that's a good thing for general neurology. It doesn't help general neurology and it further fosters that need to make the decision earlier. It becomes a vicious cycle. We're catering to the fact that they feel pressured to make that decision early, but if we didn't, they'd have to make those decisions without exposure.”
Should the fellowship application process be pushed back, at least to some degree? It would be a complicated process, but it could be done, said Jessica B. Kraker, MD, assistant professor of clinical neurology and director of the neurology residency program at Tulane University School of Medicine.
“We all agree that current system is forcing residents to choose too soon. But some subspecialties match through Accreditation Council for Graduate Medical Education/National Resident Matching Program, some through San Francisco Match, and some through a sort of handshake process with no match whatsoever,” Dr. Kraker told Neurology Today. “To change the timeline would require a lot of organizations to come together, and it could only be pushed back so far—perhaps to interviews in the second half of the PGY3 year. Because it can take six months to get fully licensed and credentialed, you'll want to know where you're going by the fall of PGY4.”
Options for enhancing general training
The neurologists interviewed for this story offered other suggestions for encouraging more training in general neurology. Among them, they recommended:
- More opportunities for advanced fellowships in general neurology fellowships, such as the one at Massachusetts General Hospital, a one-year fellowship program that exposes residents to a wide range of neurological disorders that include autoimmune disorders, infectious diseases, and complex issues in neurology; the program aims to prepare neurologists to become clinician-educators to teaching medical students and train residents in neurology. “It might seem ridiculous when you should be getting this exposure as a resident, but perhaps it would elevate general neurology's status as a desirable career,” Dr. Rubin said.
- Dr. Kennedy disagrees, however: “Neither additional year of training during the neurology residency or a general neurology fellowship is needed if the culture and the training are realigned to where they should be.”
- A requirement of one month in community neurology service in residency programs. “That, of course, would take a lot of coordination between programs and community neurologists and may not be as easy as it sounds depending on program funding structure,” Dr. Kraker observed.
- “We should also find ways to give students more opportunities in their clinic years to rotate with general neurologists in the community, so that when they become residents they will be aware of what an exciting and fulfilling career option general neurology is.”
- Restoring some of the experiences that have been lost in neurology residency. “I have a colleague who became a general neurologist but did a neuromuscular fellowship because his residency didn't teach him to do EMG studies, and he knew that was important,” said Dr. Kennedy. “Those are skills I was taught in my residency. We need to ensure that all our residencies are turning out graduates who are competent to practice general neurology.”
- Re-balance the focus of neurology residencies so that they do not overemphasize inpatient care. “Often the structure of residency programs is front loaded with inpatient duties, so residents in their PGY2 year spend a large portion of the year going to stroke activations and treating acutely ill patients such as ones in the neuro-ICU, so when it comes to career planning, they gravitate towards subspecialty fellowships, because they have worked closely with subspecialists,” said Dr. Kraker. “Especially for smaller neurology programs, there needs to be systemwide buy-in to restructure the inpatient care teams, possibly by expanding the number of faculty and non-physician providers who participate in inpatient care, so that residents have more opportunity earlier in training to participate in outpatient clinics, where they get more exposure to general neurology.”
A shift in motivation
Dr. Kraker noted, however, that today's cadre of aspiring neurologists may also have a different focus than in previous generations. “I read a lot of personal statements and applications from residents and do a lot of counseling for third-year medical students who are considering neurology as a career,” she said. “In my opinion, there has been a shift in motivations to become neurologists. When I graduated from medical school in 2005, neurology was seen as more of a primarily outpatient, non-emergent specialty. With the rapid advancements in treatments for acute neurologic issues such as stroke, there are more and more students going into neurology with the goals of acute neurologic care, focused on doing stroke, neuro-interventional, and neuro-intensive work and critical care.”
Something has to be done to change the cultural view of general neurology, Dr. Kennedy said. “General community neurology isn't a second choice. You can't dictate what residents do, but on the other hand, you have to give them a fair idea of what's out there. I'm afraid there are some definite consequences if we don't correct hits –not a trend, a tsunami. There will be poor neurological care in multiple areas where there aren't general neurologists.”
In addition, he warns against the “Balkanization of neurology,” in which the separation of the specialty into so many different fellowship groups diminishes its influence compared with larger specialties such as family practice, internal medicine and orthopedics.
Dr. Markowski had no disclosures. Dr. Rubin has spoken for Novartis Pharmaceuticals on women's issues in multiple sclerosis and received an honorarium.