Article In Brief
The expansion of new training programs in neurology for nurse practitioners and physician assistants has accelerated in recent years as directors recognize the importance of preparing those professionals to complement the work of neurologists in outpatient and inpatient settings.
When Megan Craft, PA-C, graduated from a physician assistant program, she wanted to start her neurology career feeling confident and prepared. So, she enrolled in the one-year academic residency program in neurology through the University of Kentucky's College of Health Sciences. She spent a year in Lexington working in outpatient and inpatient neurology services, participating in research and didactic learning, gleaning knowledge and experience in each subspecialty, and engaging with advanced practice provider (APP) residents in other fields.
“Given the choice to repeat this journey, it would be an easy decision,” said Craft, a physician assistant in ambulatory neurology at the university's Kentucky Neuroscience Institute.
“The residency set me up for success by greatly accelerating my learning process,” she said. “I may have eventually learned while practicing what I learned in that year, but it would have taken me several years. The opportunity to watch experienced clinicians care for their patients and teach me how to [provide that care] was priceless.”
The emergence of new training programs in neurology APPs—nurse practitioners and physician assistants—has accelerated in recent years. Their directors recognize the importance of preparing them to complement the work of neurologists in both outpatient and inpatient settings.
Joel Morgenlander, MD, FAAN, professor of neurology and orthopedic surgery at Duke University Medical Center in Durham, NC, recently organized the Consortium of Neurology APP Directors, which met on Zoom last December. About 27 people are a part of the consortium, Dr. Morgenlander said.
“We constantly evolve as clinicians and educators, so the more we can work together, the more we can learn from each other and benefit not only our trainees but [also] our patients,” said Dr. Morgenlander, who hopes to find a home for the consortium within the AAN.
He added that “the primary training of nurse practitioners and physician assistants is very much biased toward primary care, so they're not necessarily well-prepared for careers in neurology.”
“First and foremost, you don't have to reinvent the wheel. You should be able to tap into resources that are already available for physician residents and medical students.”—DR. JULIE A. GURWELL
Dr. Morgenlander has directed Duke's neurology advanced practice provider residency for eight years, and he hopes to influence other institutions to start similar programs because they have many benefits. “Neurology-trained APPs greatly expand access for outpatients, increase inpatient capabilities, perform clinical research, and function as neurology educators for learners in all types of programs,” he said.
Residency and fellowship programs for advanced practice providers in neurology have been created to meet a need for standardized, high-quality post-graduate training. “An AAN consortium would allow for collaboration between program directors, improve existing programs, and facilitate the creation of new programs, said Daniel Harrison, MD, a fellow in neurocritical care at the Mass General Brigham integrated health care system in Boston and the co-lead author of a research article on the training of physician assistants in neurology, published in March 2023 in Neurology: Education.
More than 1,000 physician assistants work in neurology in the United States, representing a 33.4 percent increase compared with 2016, according to research conducted between 2016 and 2020. But Dr. Harrison said the numbers continue to grow, and physician assistants represent only one group of advanced practice providers; the data did not account for all APPs who practice neurology, such as nurse practitioners.
However, APPs report a scarcity of neurologic education in their undergraduate degree programs, particularly in areas related to neuroradiology, neuroanatomy, and differential diagnosis.
To address those training gaps, directors of neurology advanced practice provider training programs are creating educational content and coordinating didactic teaching as well as clinical learning. “They coordinate the logistics of advanced practice provider post-graduate programs,” Dr. Harrison told Neurology Today. “They are invaluable in recruiting and training qualified advanced practice providers to support the clinical mission of neurology departments.”
These program directors are responsible for collaborating with their trainees to provide care for patients with neurologic diseases. “They work with neurologists in their department to identify preceptors to provide clinical training for advanced practice providers as well as neurologists who can assist with delivery of didactic education in their areas of expertise,” he said, adding that they also support trainees in their job search as they transition out of their post-graduate training programs.
Becoming an advanced practice provider in neurology without specialized training can be overwhelming, said Juliana VanderPluym, MD, associate professor of neurology and a headache specialist at Mayo Clinic in Scottsdale, AZ, and one of two medical directors of the Mayo Clinic APP neurology fellowship. The fellowship offers additional specialty training, as well as enables the advanced practice provider to home in on a particular neurologic area of interest, Dr. VanderPluym said.
At Mayo Clinic, APPs work in collaboration with neurologists to provide continuity of care for patients through follow-up appointments. In addition, she said, they can perform certain procedures, such as botulinum toxin injections for chronic migraine or lumbar punctures to evaluate patients for a variety of neurologic diseases, including multiple sclerosis and infections of the central nervous system.
Dr. VanderPluym acknowledged that some patients initially are hesitant about seeing an APP. Yet, as soon as patients “see how competent and caring they are, often those hesitations disappear pretty quickly,” she said.
“We have open discussions with our patients about the fact that APPs will be part of their care team, so that this isn't something that comes as a surprise to them, and hopefully [it] will minimize any complaints or concerns.”
Some APPs only see established patients, while others care for both new and established patients, depending on their subspecialty, said Julie A. Gurwell, PhD, PA-C, a professor and director of advanced practice providers in neurology at the University of Kentucky.
“They help see the patients with less complex neurologic diseases,” Dr. Gurwell said. For example, an attending epileptologist would see a patient with refractory epilepsy, whereas an APP would manage a patient who is stable on anti-epileptic medications.
When a new patient reaches out to the call center, the person answering the phone uses an algorithm to determine who would be the most appropriate health care provider before scheduling an appointment. “It's not a perfect algorithm, but it works most of the time,” Dr. Gurwell said.
There is room for growth and development opportunities for directors of APPs and neurology training programs. More resources may be available in academic medical centers than in community-based neurology programs that don't train physician residents and medical students, she said.
Dr. Gurwell noted that resources are available to neurology departments that want to create an advanced practice provider residency or fellowship. She noted that the AAN course, NeuroReady: Advanced Practice Providers Edition, covers 10 clinical neurology topics.
“First and foremost, you don't have to reinvent the wheel,” she said. “You should be able to tap into resources that are already available for physician residents and medical students.”
For instance, APP residents at the University of Kentucky attend all of the same lectures as third-year medical students. In the neuroanatomy course, they learn about the basic organization and function of the brain and spinal cord.
Daniel O. Lee, MD, FAAN, FAASM, medical director at the Kentucky Neuroscience Institute and a past president of the Kentucky Sleep Society, works one-on-one with advanced practice practitioners for the first three months in the general neurology clinic, before the start of subspecialty training, Dr. Gurwell said.
Lesli Morcom, AGNP-C, an adult gerontology nurse practitioner who works in Duke University's outpatient neurology clinic, is grateful for the knowledge gained during her participation in the institution's APP residency in neurology, which she completed in 2016.
“I learned early on that I would not have been able to survive in the neurology world as a nurse practitioner if I did not participate in this program,” said Morcom, who started at the clinic in 2011. She said caring for patients with neurologic issues on medical-surgical floors at hospitals in Texas and North Carolina—mostly involving post-stroke recovery and multiple sclerosis—piqued her curiosity about the specialty.
Then she began pursuing graduate studies at Duke University School of Nursing to become a nurse practitioner. She graduated in 2015 and enrolled in the one-year APP residency at Duke two months later.
“What I like most about my role is incorporating procedures into my clinic week,” Morcom said. “I perform [botulinum toxin] procedures for patients with upper and lower limb spasticity, dystonia, and for migraines.”
At Mayo Clinic in Scottsdale, Abigail Taylor, PA-C, program director of the APP fellowship in neurology, said the team seeks applicants who are excited about the field. She described neurology as “a fascinating and very rewarding specialty,” adding that “unfortunately, nurse practitioner and physician assistant education can fail to showcase this.”
“Neurology-trained APPs greatly expand access for outpatients, increase inpatient capabilities, perform clinical research, and function as neurology educators for learners in all types of programs.”—DR. JOEL MORGENLANDER
“The residency set me up for success by greatly accelerating my learning process. I may have eventually learned while practicing what I learned in that year, but it would have taken me several years. The opportunity to watch experienced clinicians care for their patients and teach me how to [provide that care] was priceless.”—MEGAN CRAFT
“In my experience, nurse practitioner and physician assistant students and new graduates often feel uncertain or confused about caring for patients with neurologic diseases,” Taylor said. “This is one of the reasons it can be difficult for neurology practices to recruit and retain nurse practitioners and physician assistants. The fellowship helps provide a bridge to clinical practice in neurology.”
She added that “this fellowship covers many topics in neurology, in both the inpatient and outpatient arena. Our team cares for patients with migraine, seizures, multiple sclerosis, neuropathy, acute stroke, and the list goes on and on. We also do offer opportunities for our fellows to rotate in adjacent specialties such as physical medicine and rehab and neurosurgery.” Fellows also can present at grand rounds for nurse practitioners and physician assistants, Taylor said.
Upon becoming a nurse practitioner, Sarbesh Chalise, MSN, FNP-C, enrolled in the advanced practice provider fellowship at Massachusetts General Hospital to learn about diverse diagnoses and, as part of a care team, to treat patients for possibly life-altering conditions.
“Every encounter with patients is interesting, as each patient and their story is different,” said Chalise, who expected to complete his fellowship in February. “I find it most remarkable when patients come back for follow-up appointments with their symptoms under control and they don't have anything concerning to report.”
