Abstract
Objective To report a 2017 survey of all US medical school neurology clerkship directors (CDs) and to compare the results to similar surveys conducted in 2005 and 2012.
Methods An American Academy of Neurology (AAN) Consortium of Neurology Clerkship Directors (CNCD) workgroup developed the survey that was sent to all neurology CDs listed in the AAN CNCD database. Comparisons were made to similar 2005 and 2012 surveys.
Results The response rate was 92 of 146 programs (63%). Among the responding institutions, neurology is required in 94% of schools and is 4 weeks in length in 75%. From 2005 to 2017, clerkships shifted out of a fourth-year-only rotation (p = 0.035) to earlier curricular time points. CD protected time averages 0.24 full-time equivalent (FTE), with 31% of CDs reporting 0.26 to 0.50 FTE support, a >4-fold increase from prior surveys (p < 0.001). CD service of >12 years increased from 9% in 2005 to 23% in 2017. Twenty-seven percent also serve as division chief/director, and 22% direct a preclinical neuroscience course. Forty-nine percent of CDs are very satisfied in their role, increased from 34% in 2012 (p = 0.046). The majority of CDs identify as white and male, with none identifying as black/African American.
Conclusion Changes since 2005 and 2012 include shifting of the neurology clerkship to earlier in the medical school curriculum and an increase in CD salary support. CDs are more satisfied than reflected in previous surveys and stay in the role longer. There is a lack of racial diversity among neurology CDs.
Glosssary
- AAN=
- American Academy of Neurology;
- APP=
- advanced practice provider;
- CD=
- clerkship director;
- CNCD=
- Consortium of Neurology Clerkship Directors;
- FTE=
- full-time equivalent;
- LCME=
- Liaison Committee on Medical Education
Neurology clerkships provide essential clinical training to medical students. The goal of the neurology clerkship is to ensure that all graduating medical students develop the medical knowledge and clinical skills to identify and care for patients with common or emergent neurologic symptoms and disorders, regardless of their selected specialty. The neurology clerkship also provides an opportunity for medical students to explore clinical neurology and to be exposed to neurologists and their colleagues, and it provides an opportunity to identify and train the next generation of neurologists and clinical neuroscientists.1 The current gap between the supply and demand in the country's neurology workforce is expected to continue in the near future.2
In response to the expanding science of neurology and regulatory changes to curricular delivery methods, clerkship directors (CDs) have a responsibility to adapt their programs. The Consortium of Neurology Clerkship Directors (CNCD) of the American Academy of Neurology (AAN) performed prior surveys of US neurology CDs in 2005 and 2012. The 2012 survey identified themes that included shorter clerkships, shifting the clerkship from the fourth to the third year in the medical school curriculum, and an increasing use of technology.3 Overall, CDs reported being satisfied but having inadequate protected time and departmental support.3
Since the 2012 survey, 12 new allopathic medical schools opened, and existing medical schools reformed their curricula on the basis of the 2010 Carnegie Report.4 Common themes in curriculum reform include shortening the foundational (preclerkship) curriculum, offering clinical clerkships earlier in the curriculum, providing opportunity for individualized scholarship, and delaying administration of the National Board of Medical Examiners Step 1 examination until after the clerkships.5 In addition, the Liaison Committee on Medical Education (LCME) updated many accreditation standards for medical schools, including new requirements for clerkships.6 As a result of shifts in curricula and accreditation standards and to assess the themes found in prior surveys, a new survey was developed by the CNCD in 2017 to assess changes across the US medical school neurology clerkships.
Methods
The 2017 survey was developed from a revision of the 2012 survey by members of a work group of the CNCD of the AAN, with the intent of maintaining as many questions in the same format as possible to maximize the comparability of the surveys. Additional questions were added pertaining to education research, other CD educational roles, additional clerkship leaders such as associate directors, student mistreatment, demographic characteristics, and mentorship roles.
The survey contained a total of 68 questions with the option to add free-text responses for selected questions. The survey questions data are available from Dryad (appendix, doi.org/10.5061/dryad.gh49142). The survey was reviewed by the AAN Insights team and approved by the Member Research Subcommittee. The survey was finalized in May 2017 and conducted solely online between May and September 2017. A roster containing all 147 US CDs was obtained from the AAN internal membership database on May 17, 2017. The survey was distributed on May 18, 2017, and was signed by the chair of the CNCD. Responses were confidential, but AAN staff were able to track nonrespondents. Personalized reminder e-mails to nonrespondents were sent in June, July, and September 2017. Data collection closed in September 2017. One program indicated a change in leadership during data collection, for a final survey population of 146 programs.
Standard descriptive statistics were used to characterize survey responses. Subset data analysis was performed to identify associations between CD sex and academic rank, CD support, age, and years as CD; timing of the clerkship and number of medical students applying to a neurology residency; CD support and burnout and years in role; and faculty compensation for full-time equivalent (FTE) and the inclusion of teaching efforts in promotion decisions. The proportions of CDs choosing a response in 2005, 2012, and 2017 were compared and tested for significance with χ2 tests, 2-sided significance, with type I error (α) set to 0.05. All statistical analyses were performed with IBM SPSS Statistics version 24 (Armonk, NY).
This survey project was reviewed by the Weill Cornell Medicine institutional review board and was granted exempt status because the nature of the survey reflects educational practices and noninvasive survey data (protocol 1703018027).
Data availability
Any data not published in the article will be shared by request from any qualified investigator.
Results
The response rate for the 2017 survey was 63% (92 of 146 programs), which was lower than the 2012 and 2005 surveys (73.1% in 2012 and 75% in 2005, p = 0.066). However, the number of surveyed CDs increased substantially since the 2005 survey from 109 to 146.
Structure of the neurology clerkship
Timing
The percentage of respondents reporting that the neurology clerkship is required at their institution remained stable (93% in both 2012 and 2005 and 94% in 2017). The clerkship continues to be scheduled exclusively during the third year in about half of the respondent institutions (table 1). There has been a decline in the proportion of clerkships offered exclusively during the fourth year, from 23% in 2005 to 9% in 2017 (p = 0.035), and an increase in the proportion of clerkships offered in other years (0% in 2005 to 16% in 2017, p = 0.002). This includes clerkships offered in the second year, as well as longitudinal models. The clerkship duration is 4 weeks at 75% of schools and 3 weeks at 11% of schools in both 2012 and 2017. The percentage of schools offering a longitudinal integrated clinical curriculum is 25%, which has increased from 22% in 2012. Neurology is part of a combined clerkship block in 26% of schools, which is similar to 2012 and 2005. The other disciplines in these combined blocks include psychiatry (63%), pediatric neurology (33%), and neurosurgery (21%).
Clerkship details
Curricular and clinical experiences
Although most medical schools assign students to academic institutions for the clerkship, schools also use a variety of other teaching sites, including community, county, pediatric, and Veterans Affairs hospitals. Outpatient assignments are common, with 85% of students spending time in outpatient clinics at academic centers and 76% at Veterans Affairs, county, or community settings. Students evaluate an average of 5 inpatients and 6 outpatients per week during the neurology clerkship. Although few students perform a lumbar puncture during the clerkship, 53% of programs offer simulation training. Students spend ≈25 hours per rotation on structured educational activities, which most frequently include lectures, but online learning and small group teaching are also common.
Sixty-nine percent of students are observed by faculty while obtaining a neurologic history and performing an examination during a live patient interaction. A variety of resources are used during the neurology clerkship. Sixty-one percent of respondents use the AAN Neurology Clerkship Core Curriculum.7 Fifty-nine percent recommend a specific text. Of the 77% who use online resources, the most common are lecture videos (57%), e-books (52%), the AAN Medical Student Self-Assessment Examination (44%), neurology apps (41%), online case simulations (25%), and podcasts (18%). Eighty-four percent of respondents mandate student exposure to patients in specific diagnostic categories to fulfill LCME standards. Most commonly used alternative methods to fulfill this requirement include patient videos and simulated patients. Eighty-six percent of programs have between 2 and 9 students apply to neurology residency programs per year. Only 11% have between 0 and 1 students and 3% have >10 students.
Structure of neurology elective experiences
Similar to the prior surveys, most medical schools offer neurology subinternships (77% in 2017, 71% in 2012, and 73% in 2005). Several other neurology electives are offered at many schools. On the basis of the current survey, 74% offer a neurology subspecialty elective, which increased from 62% in 2005 and 63% in 2012. Common neurology electives include ambulatory neurology, neurointensive care, and neurology research. Most schools (80%) require a core neurology clerkship as a prerequisite for these electives. The proportion of schools with >10 students per year taking neurology elective increased from 13% in 2005 to 30% in 2017 (p = 0.019).
Faculty teaching in the neurology clerkship
Ninety-six percent of clerkship students are taught by full-time university faculty. The proportion of students taught by part-time or volunteer faculty fluctuated over the past 12 years, from 47% in 2005 up to 68% in 2012 and down to 48% in 2017. The proportion of community or private practitioners teaching students also fluctuated (42% in 2005, 29% in 2012, and 42% in 2017). Asked for the first time in 2017, advanced practice providers (APPs) teach medical students in about one-third (34%) of neurology clerkships. Fifty-five percent of clerkships use off-campus community sites for teaching students. The majority of community faculty (71%) are not paid for their teaching efforts. When financial compensation is provided, it is most often through a direct stipend or salary support (71%). Adjunct or voluntary faculty appointments are given to 93%. Most respondents report no salary support being provided to academic faculty teaching medical students (64%).
There has been an increase in the recognized importance of teaching efforts in the promotion process between 2005 and 2017 (p = 0.028, table 2). Ninety percent use a variety of education-related faculty development opportunities, including workshops held locally (80%) and nationally (28%), individual mentoring (30%), degree programs (19%), and online courses (14%). Almost half (47%) of CDs receive financial support to attend the AAN annual meeting. The majority of respondents (60%) perceive that student mistreatment, abuse, intimidation, and negative learning environment are reported less by students in the neurology clerkship compared to other clerkships at the institution, whereas 19% indicate it is the same and 20% do not know.
CD support
Evaluation methods for the neurology clerkship
Direct observation of students by faculty and residents is the largest weighted component of the final grade (mean 43%). The second highest component is the National Board of Medical Examiners clinical neurology participant examination or “shelf exam” (mean 21%). Other methods used for grading and the mean percentage contribution to the final grade include the following: graded elements of documentation (10%), attendance and participation (8%), objective structured clinical examinations (5%), written essays (4%), or oral examinations (2%). The shelf exam is used by the majority (80%) of clerkships. Reasons for not using it include cost (44%), misalignment with learning objectives (28%), and preference for another form of assessment, including locally produced written examinations (34%) or bedside observation exercises (28%).
To assign a final grade, only 6% of clerkships use a pass/fail system, with the remainder using a grading range, most commonly honors/high pass/pass/fail. Most clerkships use competency-based grading (58%); the others use some form of a normative curve. Clerkships most often obtain feedback from students for program evaluation with written or online forms (98%). Additional methods include group (36%) and individual (33%) interviews with students. Information from faculty and house officers about the program is most often obtained from informal discussions (81%), group interviews (34%), and individual interviews (29%). Other methods include formal written or online forms (27%), education retreats (17%), and as-needed surveys (2%).
Departmental and institutional support for the neurology clerkship
The mean protected time, or FTE, for effort as a CD is 0.24 (range 0–0.6 FTE), with 6% of CDs reporting 0. The mean FTE support perceived as needed is 0.35. In 2012, the mean protected time was 0.20 FTE and mean perceived need was 0.32 FTE.3 Support has increased over the past 12 years, with 31.4% of CDs receiving between 0.26 and 0.50 FTE in 2017 compared to 6.5% in 2005 (p < 0.001). Perceived need also increased, with a greater proportion of CDs indicating that they should receive 0.26 to 0.50 FTE protected time (p < 0.001). A small majority of CDs have an assistant, associate, or codirector for the clerkship (57%). The mean protected time for these positions is 0.17 FTE. The average support for coordinators or administrative staff is 0.43 FTE. The majority report their department chair's enthusiasm for the clerkship mission as “great” (57%), with 34% reporting “some enthusiasm.”
CD profile
Among respondents, the average CD age is 50 years with a range of 34 to 73 years, and 58% identify as male. Seventy-one percent of respondents identify as white, with 22% identified as Asian and 12% as Latino or Hispanic. None of the respondents identify as black/African American. Most CDs are full-time academic faculty (91%). There is a wide distribution of academic ranks among respondents (table 3). Most use a clinical educator promotion track (58%); however, a sizeable proportion (23%) report that this is not an option at their school.
CD demographics
Among respondents, the average tenure as a CD is 9 years (range 0–30 years). Academic rank, FTE, age, and years in the role do not differ between men and women. The majority of neurology faculty at the responding institutions (89%) are involved in administering preclinical courses, and among those who do, the courses include neuroscience (96%), introduction to clinical medicine courses (21%), integrated longitudinal clinical curricula (14%), and neuropathology (13%). CDs are often involved in diverse administrative roles (80%). These include division or section chiefs (33%), vice chairs or other departmental directorships (32%), hospital or clinical administrators (22%), or fellowship directors (19%). Ten percent are also the residency program director. Most are involved with medical school and departmental committees (98%). Examples include clinical curriculum, departmental education, medical student promotions, and graduate medical education. Most CDs and associate CDs are also involved in formal and informal mentorship programs outside of clerkship responsibilities (82%).
Among respondents, fewer than half of CDs are involved in medical education research (44%); of those who are not, most are interested (73%). Among those who are interested or are conducting medical education research, most identified several needs to develop a career incorporating education research (88%). These include learning statistical methods, networking and collaboration, knowledge of research design, educational interventions, and outcomes.
Among respondents, most CDs are very or somewhat satisfied with their role (96%, table 4), but 50% experience at least infrequent burnout with the role and 15% experience it frequently. There is an increase in satisfaction compared to 2012 (p = 0.027). Thirty-one percent have considered relinquishing the role in the next 12 months, citing several reasons, the most common being competing obligations (56%).
CD satisfaction
Discussion
Neurology education continues to play an important role in medical schools across the United States, with most responding schools having a required 4-week clinical neurology experience, mostly during the third year. However, as new models of curriculum delivery are implemented, neurology clerkships increasingly are being offered earlier in the curriculum, as early as the second year, or through longitudinal experiences. Earlier exposure to neurology is an encouraging finding because fourth year clerkships likely occur too late in training for students to allow time to decide on a career in neurology. As medical school curricula evolve, it is important to ensure that these new models of education do not diminish the role of neurologic education.
Results of this survey indicate that there is an opportunity to enhance neurology clerkship curricula by further incorporating direct observation of history taking and physical examination skills because this is currently a component in only 69% of clerkships. Observation of these skills in the neurology clerkship is included in the Association of American Medical College's annual Graduation Questionnaire and is an LCME accreditation standard for clinical clerkships.6
It is important and encouraging to note that institutional and departmental support provided to CDs has been increasing over the years, up to an average of 0.24 FTE. In 2005, more than one-third of CDs reported receiving <0.05 FTE, but in the current survey, nearly one-third report receiving between 0.25 and 0.5 FTE. However, the mean protected time of 0.24 FTE is below the 0.35 FTE that CDs believe is needed to effectively administer the clerkship. In about half of the institutions surveyed, this might be partially compensated for by the use of assistant or associate CDs.
Although the large majority of students are taught by full-time university faculty, half of the clerkships use off-campus teaching sites, and the involvement of uncompensated voluntary faculty is common. With the ever-increasing administrative practice burdens on community neurologists, academic medical centers should consider ways to ensure that adding students benefits, rather than strains, practices.8 Models describing effective use of students in neurology clinics demonstrated the ability to increase overall clinical productivity.9 Academic medical centers should partner with their community sites to implement similar models. Full-time academic faculty face competing demands to meet work relative value units, and salary/FTE support should be provided to retain those who teach medical students. Department chairs should advocate for educator support from deans and hospital administrators. The institutions can also promote the value of their teaching efforts in the promotion process.
As more academic neurology departments hire APPs, about a third of surveyed CDs report the participation of APPs in helping with educational efforts. APPs often lack faculty appointments, although LCME standards require that APPs who teach medical students work under faculty supervision. Therefore, CDs should ensure that they are not inadvertently failing to meet LCME standards, especially if students are working with APPs in nonacademic sites. We did not survey the role of APPs in student education or how they are trained to work with students, but these are important topics for further exploration.
Although burnout is common among neurologists, neurology CDs generally report a high degree of job satisfaction.10 About half of surveyed CDs report being at least very satisfied in their role, a significant increase from previous surveys. CDs are staying in the position longer, currently an average of 9 compared to 7 years in the 2012 survey. Possible explanations for increasing satisfaction and longevity in the role include the increased perceived interest in the clerkship from chairs, the increase in FTE support, and the availability of assistant directors and coordinators.
The lack of diversity among neurology CDs is a striking finding in this survey, with less representation of women and Hispanics and a lack of black/African American representation. CDs represent the front-line ambassadors of neurology to medical students around the country. Efforts are clearly needed to increase minority involvement in neurology education leadership.
Despite a lower response rate than in past years, a strength of this survey is that the absolute number of CDs completing the survey remains high (n = 92). Another strength of the survey is the use of similar items from previous years, allowing historical comparisons. The limitations include the inability to externally verify the data and possible respondent bias, especially from medical schools without required clerkships. As mentioned in Methods, standard descriptive statistics were used to characterize survey responses, and inferential statistics (χ2 tests) were used to perform between-year comparisons. It is unlikely that all respondents are independent of one another due to some CDs responding to earlier versions of the survey, which may weaken the between-year statistical comparisons. Despite this, we feel readers appreciate the inclusion of inferential statistics.
We believe that future directions for the CNCD survey should include more questions about education research and the expanding role of APPs in neurology education. Future surveys can also further explore models of integrating community neurologists into student education programs. In addition, the effect of longitudinal clinical curricula on neurology education should be explored. Many CDs wrote in free-text comments, and future studies could be done to analyze common themes in the comments to develop questions for future surveys.
The state of clinical neurology education is stronger than it was in prior CD surveys. Clerkships are required in almost all responding schools and occur earlier in the curriculum. CDs are more satisfied, stay in the role longer, have more financial and administrative support, and perceive their roles as teachers as being more important for promotion. Efforts should be made to increase the diversity of CDs and to support faculty educators.
Author contributions
Joseph E. Safdieh: study concept and design, acquisition of data, analysis and interpretation of data, study supervision. Adam D. Quick, Pearce J. Korb, Diego Torres-Russotto, and Karissa L. Gable: study concept and design, acquisition of data, analysis and interpretation of data. Maggie Rock: acquisition and interpretation of data. Carolyn Cahill: study design, statistical analysis, interpretation of the data, revising the manuscript for intellectual content. Madhu Soni: analysis and interpretation of data, critical revision of manuscript for intellectual content.
Study funding
No targeted funding reported.
Disclosure
J. Safdieh: royalties from Elsevier, editorial stipend from AAN. A. Quick and P. Korb report no disclosures relevant to the manuscript. D. Torres-Russotto: consultant or a speaker for the following companies: Abbvie, Adamas, Allergan, American Parkinson Disease Association, the Davis Phinney Foundation, GKC, Ipsen, Lundbek, Parkinson Disease Foundation, Sunovion, and Teva. K. Gable: consultant for CSL Bhering. M. Rock and C. Cahill: employee of the AAN. M. Soni reports no disclosures relevant to the manuscript. Go to Neurology.org/N for full disclosures.
Publication history
Received by Neurology April 9, 2018. Accepted in final form June 14, 2018.
Acknowledgment
The authors thank the AAN's Undergraduate Education Subcommittee and Education Committee for their review of the manuscript and all of the CDs who responded to the survey.
Footnotes
Go to Neurology.org/N for full disclosures. Funding information and disclosures deemed relevant by the authors, if any, are provided at the end of the article.
See page 695
- Received April 9, 2018.
- Accepted in final form June 14, 2018.
- © 2018 American Academy of Neurology
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