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Clinical neurophysiology education in residency.

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POINT OF VIEW
Clinical Neurophysiology Education
in Residency
In the interest of improving our specialty of neurology,
consider the following assertions: (1) Three years of
residency training are no longer sufficient to teach and
assimilate all the neurological knowledge and clinical
skills needed by a modern neurologist. (2) Too many
clinical neurophysiological studies are performed
poorly. (3) The usual 2 to 3-month training period in
clinical neurophysiology during residency often is not
sufficient to ensure clinical and technical expertise.
These statements are deliberately provocative. I
hope that they will encourage a dialogue among the
Association of University Professors of Neurology,
neurological training program directors, and other
leaders in our field and result in some overdue changes.
My opinions have been derived from service on the
Residency Review Committee (RRC) for Neurology
and the Board of Directors of the American Board of
Psychiatry and Neurology (ABPN), as well as from
many years of active clinical neurological practice.
However, I write entirely as an individual and do not
represent the views of either the RRC or the ABPN.
The RRC accredits all training programs in neurology
and child neurology for the Accreditation Council for
Graduate Medical Education and will soon accredit
clinical neurophysiology training programs as well.
Years ago, neurological training was a leisurely
paced activity. Many training programs devoted 6 to
12 months to “neuropathology.” This time was used
also for correlation of other basic sciences, such as neuroanatomy, neurochemistry and neurophysiology, with
clinical neurology. The remainder of the 36-month
training period was devoted to clinical neurology, primarily inpatient, and some clinical neurophysiology
(more electroencephalography than electromyography)
and neuroradiology (mainly angiography, myelography, and pneumography). Elective time in various subspecialties or for research seemed plentiful.
Today, the Special Requirements for Residency
Training in neurology mandate that 18 of the 36
months of training must be in adult neurology and 3
in child neurology (or 12 months in child neurology
and 12 in adult neurology for those training in child
neurology) 111. The remaining months include a variety of activities that vary from program to program and
increasingly emphasize outpatient experiences. The
trainee must receive an adequate background in “neuroanatomy, neuropathology, neurophysiology, neuropsychology, neurochemistry, neuropharmacology, and
the application of genetics and epidemiology to neurological disorders” {l], as well as “the opportunity to
acquire familiarity with the principles of psychopathology” { 11. Furthermore, residents must have “adequate
opportunities to learn the management techniques of
physical medicine and rehabilitation” {I} and should
have “education, training and experience in the management” 11) of patients with chronic neurological illnesses.
As all who participate know, residency now is an
intensely busy time. Clinical neurological knowledge
has expanded, particularly in therapeutics, and additional training often is offered in many specialized areas, such as movement disorders and muscle and peripheral nerve diseases. Experience in neurosurgery
and neuro-ophthalmology is considered important.
Training in neuroimaging, particularly computed tomography and magnetic resonance imaging, and neuroradiology is sometimes provided in a block of time,
but in most programs is obtained through conferences
and daily film reading. Education in electromyography
(EMG) and electroencephalography (EEG) is part of a
2 to 3-month block in most programs, but simultaneous clinical duties frequently cut into this time significantly, lessening exposure to teaching and the number of procedures performed or EEG records read with
supervision. The RRC has not yet set standards for
numbers of procedures that should be performed by
the trainee in the various aspects of clinical neurophysiology, including evoked responses and sleep studies.
Likewise, no time of training in neuroradiology and
neuroimaging within the residency years has been mandated.
When I look at advertisements for available neurological practice opportunities, I am struck by the many
requests for expertise in clinical neurophysiology and,
in some instances, neuroimaging skills as well. This is
not surprising inasmuch as the economics of neurological practice are well understood by both practice directors and resident trainees. More money can be made
more quickly by doing a procedure than by providing
a cognitive service. Any neurologist who has a large
consultation practice that includes referrals from other
neurologists may agree with my observation that some
patients receive EMGs and EEGs that add little to the
information needed for diagnosis and management, or
that are unnecessary. Many EMGs are performed at
the behest of neurosurgeons and orthopedists, presum-
658 Copyright 0 1993 by the American Neurological Association
ably as a shield against a malpractice claim. In addition,
my experience has been that a number of such studies
are poorly or incompletely performed.
Conversations with several leading clinical neurophysiologists have reinforced my view that 2 to 3
months of experience in clinical neurophysiology usually is insufficient to train many residents adequately in
necessary techniques and to develop a thorough understanding of the limits, value and interpretation of these
studies. This is particularly true because no minimum
number of personally performed procedures has been
defined yet. Although this judgment may appear inappropriate for some programs and trainees, the opportunity to review every adult and child neurology training
program in the United States has emphasized the great
variation among them in the quality of clinical neurophysiology education. Only the most prestigious training programs, which get an excess of resident applicants, can afford to insist that good training in clinical
neurophysiology, particularly EMG, should encompass
at least 6 months.
I do not believe that the best remedy for this problem would be for the RRC simply to define a bare
minimum number of procedures to be performed in a
2 to 3-month period. Is there another solution that
would benefit our profession, our patients, and trainees? I believe that there is. The ABPN has just begun
issuing a certificate of Added Qualifications in Clinical
Neurophysiology to certified neurologists who meet
either a training or a practice requirement and who
pass a written examination. In the near future, the majority who take this examination will be required to
complete at least 1 year of fellowship training in clinical
neurophysiology in a program accredited by the Accreditation Council for Graduate Medical Education
(through the RRC in Neurology). This certification
process offers program directors the opportunity to
state, without fear of losing resident applicants, that
training in clinical neurophysiology in the residency
will be restricted to providing an understanding of neurophysiological principles and practice. The emphasis
should be on the use and interpretation of these tests
and their synthesis with other diagnostic information.
For those who wish to develop the technical and clinical expertise to perform these studies, and not every
resident will wish to do so, the neurophysiology fellowship is the answer.
I would anticipate that if this pattern of training becomes universal, hospital credentials committees will
take cognizance of it in making decisions about who
can read and perform EEGs and EMGs in practice.
Exceptions or special considerations for credentialing
may be necessary in rural areas with few neurologists
compared with urban areas with many. An analogy
with cardiology can be made. Many physicians learn
to perform and interpret electrocardiograms (EKGs)
during their residency. Hospital credentials committees, however, often pay close attention to the type
and duration of specific training when making a determination as to whom to appoint to an EKG panel.
If all neurology programs adopt this proposal,
through the mechanism of an RRC mandate, no single
program will be at a disadvantage. An additional benefit is that further time would be available in the residency for broadening the education of neurologists in
other areas, such as psychiatry, rehabilitation, neurosurgery, and the basic sciences, which usually receive
inadequate attention in most programs. Because many
residents use their elective time for extra clinical neurophysiology experience beyond the regularly scheduled training, that elective period could be used instead
for other educational activities to produce a more
broadly trained neurologist.
I am familiar and sympathetic with the debt burden
of most residents and arguments that prolonged training will increase this. However, these considerations
must be balanced by our increasing responsibility to
produce better trained neurologists who perform only
necessary clinical neurophysiological studies, and who
do these very well. In this manner, we will benefit our
patients and society. In essence, my proposal for clinical neurophysiology training is similar to fellowship
programs used by other disciplines for procedurally
oriented subspecialties such as internal medicine.
I wish to thank Steven Ringel, MD, and Stephen Scheiber, MD, for
constructive criticism.
Stuart A. Schneck, M D
University of Colorado Health Sciences Center
Denver, CO 80262
Reference
1. 1991-1992 Directory of graduate medical education programs
accredited by the Accreditation Council for Graduate Medical
Education. Chicago, I L American Medical Association, I99 1:
57-62
Point of View: Schneck: Clinical Neurophysiology Education in Residency
659
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