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April 23, 2019; 92 (17) Article

Characteristics of graduating US allopathic medical students pursuing a career in neurology

Laurie Gutmann, Carolyn Cahill, Justin T. Jordan, Charlene E. Gamaldo, Veronica Santini, Imran Ali, Madhu Soni, Rujuta B. Wilson, Rana Said, Barry M. Czeisler, A. Gordon Smith
First published March 29, 2019, DOI: https://doi.org/10.1212/WNL.0000000000007369
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Abstract

Objectives To identify factors associated with medical students becoming neurologists because, despite the increasing burden of neurologic disorders, there is a growing neurologist shortage.

Methods Deidentified data from the Association of American Medical Colleges Matriculating Student Questionnaire (MSQ) and Graduation Questionnaire (GQ) were obtained for the graduation years 2013 to 2014 through 2016 to 2017. Logistic regression was used to assess demographic characteristics and responses to training and career-related questions in association with specialty choice (intent to enter neurology).

Results Of the 51,816 students with complete data, 1,456 (2.8%) indicated an intent to enter a neurology residency. Factors associated with an increased likelihood of entering neurology were a student's rating of excellent for their basic neuroscience course and neurology clerkship, participation in an MD/PhD program, majoring in neuroscience or psychology as an undergraduate, a selection response of “content of the specialty was a strong influence on career choice,” and indicating interest in neurology on the MSQ. Factors associated with a decreased likelihood of entering neurology were a higher-priority response on the GQ for salary, work/life balance, and personal fit of the specialty.

Conclusion Data from surveys at the entry into and graduation from medical school suggest several approaches to increase the number of medical students entering neurology, including a focus on the student-reported quality of the basic neuroscience course and neurology clerkships, targeted engagement with MD/PhD students, and mentoring programs for students interested in neurology. Efforts to improve salaries for neurologists, to reduce medical school debt, and to improve work/life balance may also help to attract more students.

Glossary

AAMC=
Association of American Medical Colleges;
AAN=
American Academy of Neurology;
CI=
confidence interval;
GQ=
Graduation Questionnaire;
IRB=
institutional review board;
MSQ=
Matriculating Student Questionnaire;
NA=
not applicable;
OR=
odds ratio

Neurologic disorders are among the leading causes of disability worldwide. Between 1990 and 2016, 2 of the 5 leading causes of years lived with disabilities were neurologic disorders, with neuropsychiatric disorders accounting for 35% of the total disease burden. For women, neurologic and psychiatric conditions account for the majority of these disorders, resulting in even higher years lived with disabilities.1 Fifty million Americans are diagnosed with a new neurologic disorder each year, yet there are only 16,000 neurologists in the United States, a workforce deficit of 11% that is projected to increase to 19% by 2025.2 Neurologists often serve a role similar to the primary health care providers for their patients; however, average wait times for visits can be >6 weeks.3 Despite the unmet demand for neurologic care, the percentage of medical students entering neurology has been persistently inadequate (at ≈2.6%/y), with only 421 graduates of US allopathic (MD-granting) medical schools expressing intent to neurology in 2017.4

Research on medical student selection of neurology as a career choice continues to implicate “neurophobia” as a prominent deterrent.5,–,9 Despite the popularity of the theory, neurophobia may not be the only limiting factor.10,11 More recently, reports focusing on other strategies such as implementation of mandatory third-year neurology clerkships12 and longitudinal mentorship programs13 appear to encourage selection. To date, there are insufficient data to validate the effectiveness of these measures.

The objective of this study was to use the Association of American Medical Colleges (AAMC) Matriculating Student Questionnaire (MSQ) and Graduation Questionnaires (GQ) to explore the factors that influence medical students to choose neurology or nonneurologic specialties as a career. Many of the assumptions regarding factors that may influence medical students choosing to enter neurology residency are based on interviews or observation. In addition, the data that are available are based on the perspective of those who have already chosen neurology as a specialty or through interviews at single sites. This study attempts to develop a better unbiased understanding of the factors that influence this career decision by using the data from multiple sites available through this national database.

Methods

Funding

This study was funded by a grant from the Conrad N. Hilton Foundation to the American Academy of Neurology (AAN) (principal investigator A.G.S.). The grant supported the data collection and analysis for this study, as well as resources to support the development of programs and initiatives to increase student interest in neurology. The AAN has provided matching budgetary support for these efforts.

Study design

The AAMC provided deidentified responses to selected items from the GQ for respondents who graduated in academic years 2013 to 2014 through 2016 to 2017 and associated individual responses to the corresponding MSQ. Data from multiple AAMC application sources supplemented the demographic variables (e.g., the American Medical College Application Service, the Medical College Admission Test, Electronic Residency Application Service). The MSQ is administered in June through September of the first year of medical school, and recent response rates ranged from 65% to 74%. The GQ is administered in February through June of the final year of medical school, and response rates were between 80% and 82%. The AAMC sponsors the Liaison Committee on Medical Education, which is the accrediting body for US MD-granting medical colleges, limiting the dataset to US allopathic medical students.

Standard protocol approvals, registrations, and patient consents

This study was reviewed by the institutional review board (IRB) at the University of Utah and considered IRB exempt (IRB No. 00105172).

Variables

The dependent variable for the bivariate and multivariate analyses was the response “neurology or subspecialty” to the GQ question “When thinking about your career, what is your intended area of practice?” The authors reviewed all GQ and MSQ items and selected independent variables using a consensus building process. Selected variables included demographic characteristics and questions from the GQ and MSQ considered potentially relevant to specialty choice on the basis of a review of the existing literature. Five demographic variables, 11 GQ questions, and 1 MSQ question were examined in association with the dependent variable for both bivariate chi-square analyses and in a logistic regression model. Demographic variables included age, sex, race/ethnicity, and school ownership (public vs private).

Four neurology-specific questions from the GQ were selected as independent variables: basic neuroscience course rating, neurology clerkship rating, effectiveness of neurology faculty teaching during clerkship, and effectiveness of neurology resident teaching during clerkship. Students with missing responses to the first 2 questions were dropped from the analysis (n = 1,920). Those answering “not applicable” (NA) to the neurology clerkship question were included as a separate group. There was not an NA option for the effectiveness of faculty teaching in the neurology clerkship, so missing responses for that question were included in the analysis to avoid dropping students who may not have completed their neurology clerkship at the time of the questionnaire. Missing responses for the effectiveness of resident teaching in the neurology clerkship were kept in the analysis for the same reason. When diagnostics were run for the logistic regression, faculty and resident teaching questions were found to correlate with the ratings for the neurology clerkship. To avoid collinearity, responses to the faculty and resident teaching questions were grouped, and the resulting variable was divided into strongly agree vs all other ratings and missing response. Three variables were based on responses/characteristics before starting medical school: response to specialty preference on the MSQ (neurology, not neurology), undergraduate major (psychology, neuroscience, all other majors), and application to an MD/PhD program (applied and accepted, applied and rejected, did not apply).

The GQ includes 9 general questions on factors influencing specialty choice: competitiveness of specialty, mentors/role models, salary expectations, work/life balance, fit with personality/interests/skills, content of specialty, debt, fellowship options, length of residency, and family expectations/plans. The first 6 were considered most relevant to choosing a career in neurology and were included in the logistic regression analysis. For simplicity, responses to the specialty-influencing questions were grouped into 2 categories: strong influence vs all other ratings (moderate, minor, no influence). Self-reported medical school debt on the GQ was used to evaluate the association of debt with career choice. Responses to medical education debt were grouped into low ($0–$15,000), low-medium ($15,001–$150,000), medium-high ($150,000–$200,00), and high ($200,001–$600,000).

Statistics

Univariate descriptive statistics were calculated across the 4 years of data (i.e., year of data was ignored). Bivariate analyses measured the significance of the associations between independent variables as a function of the dependent variable career choice (neurology vs not neurology) using the Pearson χ2 tests for categorical variables and independent t tests for continuous variables. Univariate and bivariate analyses were limited to the students included in the logistic regression model. Logistic regression analysis was conducted to determine the association of independent variables on neurology career choice. A sensitivity analysis was performed to determine whether the significant factors within the model would be replicated with different groups of students by randomly placing half the students into 1 of 2 groups and running the logistic regression for both groups. All analyses were conducted with SPSS version 24 (SPSS Inc, Chicago, IL).

Data availability

The data used in this study were provided by the AAMC and cannot be shared per a Data Licensing Agreement. Readers who would like to access the dataset should contact the AAMC.

Results

A total of 74,913 medical students graduated in the United States from MD-granting institutions during the period of 2014 to 2017. Of those, a total of 60,655 students responded to the GQ between 2014 and 2017, of whom 51,816 (85.4%) had sufficient demographic and GQ response data to be included in the logistic regression. Among these, 1,456 (2.8%) indicated that they were planning to enter neurology after graduation. The proportion of students choosing neurology on the GQ has varied from 2.6% in 2014 and 2015 up to 3.1% in 2016 and down to 2.9% in 2017.

Demographic characteristics of the sample

Trainees entering neurology were slightly older than those not entering neurology (age 27.8 vs 27.6 years, p = 0.015) (table 1). A similar percentage of women (50.7%) entered neurology compared to men (49.3%), which reflects trainees entering nonneurologic specialties. Bivariate analysis for race/ethnicity showed no significant difference between those going into neurology and those choosing other specialties (p = 0.068). The majority of students going into neurology self-identified as white (59.2%), and the second-largest group was Asian (21.2%). Those underrepresented in medicine made up 8.1% of the trainees entering neurology, while those listing other or multiple ethnicity/races made up 9.4%. This is similar to nonneurologic specialties, as noted in table 1. Compared to those not entering neurology, a larger proportion of students entering neurology were from a private medical school (43.5% vs 39.3%, p = 0.001). Of those students who were accepted into an MD/PhD program, the proportion entering neurology was almost 3-fold greater than those who were not in the combined program (p < 0.001). Of the nearly 100 listed undergraduate majors, 13.3% of those entering neurology listed an undergraduate neuroscience major compared to only 4.5% of those not entering neurology (p < 0.001). Psychology undergraduate majors also entered neurology at a higher rate compared to other specialties (8.0% vs 5.1%; p < 0.001). Students planning to enter neurology also had less mean debt compared to those who planned to enter other fields ($126,057 ± 107,730 vs $132,983 ± 105,094) (p = 0.013).

View this table:
Table 1

Demographic characteristics of study sample

Career interests, neuroscience course, and neurology

Two-thirds of students (66.8%) who indicated a specialty interest at matriculation changed their interest by graduation, as illustrated in figure 1. When asked about which specialty they were considering at matriculation (on the MSQ), respondents indicated an interest in internal medicine or one of its subspecialties most frequently (11.2%). This was followed by pediatrics (8.5%), surgical subspecialties excluding neurosurgery (7.7%), general surgery (6.2%), and emergency medicine (5.8%). Neurology was the eighth most popular specialty of 17 specialty categories, with 1,403 students (2.7%) indicating an interest. By the time of the GQ administration, neurology had dropped to number 11 of 17 as an intended area of practice (2.8%). One in 5 students entering with an interest in neurology (19.8%) retained his or her interest in the specialty throughout medical school, which was slightly above the median retention (obstetrics and gynecology 18.4%).

Figure 1
Figure 1 Change in specialty choice preference throughout medical school

Alluvial diagram representing flow of change in medical student specialty choice preference from matriculation (Matriculating Student Questionnaire [MSQ], left) to graduation (Graduation Questionnaire [GQ], right. MSQ question was, “What general specialty are you considering?” GQ question was, “When thinking about your career, what is your intended area of practice?” Students could select 1 of ≈26 specialty options, which were condensed into 17 for ease of comparison. Size of the bars is proportional to the number of students selecting the specialty, and specialties are listed in descending order of frequency. Total cases n = 51,816. Image created with rawgraphs.io/.

The basic neuroscience course was rated excellent by 65.1% of students planning to enter neurology, which was a greater proportion than those not entering neurology (45.6%, p < 0.001) (table 2 and figure 2). The neurology clerkship was also highly rated by those planning to enter neurology compared to those who planned to enter other fields (68.6% vs 33.6%, p < 0.001) (figure 3). Not all medical schools have a required neurology clerkship, with 77% reported in 2013 to 2014, increasing to 86% in 2016 to 2017.14 About 1 in 10 students (10.7%) not going into neurology selected NA for their neurology clerkship rating compared to only 2.7% of students entering neurology (p < 0.001). For the bivariate analysis, those rating either the neuroscience course or neurology clerkship as excellent were more likely to express intent to enter neurology on the GQ compared to those who did not (p < 0.001).

View this table:
Table 2

Career interests, neuroscience course, and neurology clerkship experiences

Figure 2
Figure 2 Basic neuroscience course rating

Percentage of graduating medical students who rated their basic neuroscience course as poor, fair, good, or excellent segmented by those entering neurology vs all other specialties. The Graduation Questionnaire question was, “How well did your study of basic neuroscience prepare you for clinical clerkships and electives?” The χ2 test of independence was significant (p < 0.001); each pairwise z test was significant (poor p = 0.006; fair good, and excellent p < 0.001). Cases entering neurology n = 1,456; cases entering other specialties n = 50,360.

Figure 3
Figure 3 Neurology clerkship rating

Percentage of graduating medical students who rated their neurology clerkship as poor, fair, good, excellent, or not applicable (NA) segmented by those entering neurology vs all other specialties. The Graduation Questionnaire question was, “Rate the quality of your educational experiences in the [neurology] clerkship.” The χ2 test of independence was significant (p < 0.001); each pairwise z test was significant (poor, fair, good, excellent, and NA p < 0.001). Cases entering neurology n = 1,456; cases entering other specialties n = 50,360.

Similarly, as the ratings of teaching effectiveness in the neurology clerkship increased (for both faculty and residents), the overall neurology clerkship ratings also increased (p < 0.001 for both, Pearson r = 0.666 for faculty and r = 0.547 for residents). Students entering neurology provided higher ratings for effective teaching in the neurology clerkship compared to those not entering neurology (p < 0.001 for both faculty and residents).

Those intending to enter neurology answered that competitiveness of specialty was less influential in their decision (p < 0.001) than for those not pursuing neurology (table 3). Within the bivariate analysis, students going into neurology were slightly more likely to have been influenced by mentors (p = 0.025). Although specialty fit with personality/interests/skills did not differ significantly between those planning to enter neurology and those choosing other fields (p = 0.280), it had a strong influence on specialty choice for students overall (87.9%). More students entering neurology indicated that content of the specialty had a strong influence on their decision (88.5% for neurology vs 82.7% for not neurology, p < 0.001). Work/life balance was rated as less influential for those entering neurology than for those not entering neurology (strong influence for 33.9% for those entering neurology vs 44.3% for not entering neurology, p < 0.001). Salary expectations were not very influential for those entering neurology, with only 4.5% indicating it was a strong influence (vs 14.1% of students not entering neurology, p < 0.001).

View this table:
Table 3

Factors influencing specialty choice

Logistic regression

A logistic regression model identified factors associated with choosing neurology as a career (table 4). The full logistic regression model was statistically significant (χ2 = 1985.6, df = 31, p < 0.001), and 51,816 students were used in the model (neurology n = 1,456, not neurology n = 50,360). The Cox and Snell and Nagelkerke R2 values were 0.04 and 0.17, respectively. With an α of 0.01, demographic characteristics were not significant (age, sex, race/ethnicity, school ownership, having dependents, and debt). Sensitivity analysis of randomly splitting the cohort into 2 groups resulted in the same significant characteristics as the full model.

View this table:
Table 4

Logistic regression model of factors associated with choosing neurology as a career

Acceptance into an MD/PhD program more than doubled the likelihood of going into neurology (odds ratio [OR] 2.53, 95% confidence interval [CI] 2.07–3.10), whereas rejection from an MD/PhD program was not significant in this decision. Having a neuroscience undergraduate major more than doubled the odds of going into neurology (OR 2.25, 95% CI 1.89–2.68), and having a psychology undergraduate major increased the likelihood by 54% (OR 1.54, 95% CI 1.25–1.89). Indicating an interest in neurology at undergraduate matriculation was associated with a >8-fold greater odds of entering neurology (OR 8.53, 95% CI 7.29–9.97).

Neurology clerkship ratings were a significant predictor of whether a medical student was likely to enter neurology. As the neurology clerkship rating decreased, the likelihood of a student entering neurology also decreased. Those who rated their neurology clerkship as excellent had a more than doubled likelihood of going into neurology compared to those who rated it good (OR 2.31, 95% CI 1.98–2.69), whereas those who rated it as poor had a 74% lower likelihood (OR 0.26, 95% CI 0.17–0.40). Rating the clerkship as NA, implying no clerkship done to that point (OR 0.25, 95% CI 0.18–0.36), had an effect similar to that of rating it as poor.

For the basic neuroscience course rating, giving a rating of excellent increased the likelihood of a student entering neurology by 44% compared to those who rated it good (OR 1.44; 95% CI 1.26–1.64). The other ratings, which were significant in the bivariate analysis, were not significant for the logistic regression. Effectiveness of teaching within the neurology clerkship by both faculty and residents was significant. Those who strongly agreed with the statement “faculty provided effective teaching during the neurology clerkship” had a 50% higher likelihood of entering neurology (OR 1.50, 95% CI 1.30–1.73). Similarly, those who strongly agreed with the effectiveness of resident teaching within the neurology clerkship had a 39% higher likelihood of entering neurology (OR 1.39, 95% CI 1.23–1.57).

Indicating a strong influence for the following factors decreased the likelihood of entering neurology: salary expectations (OR 0.33, 95% CI 0.25–0.42), work/life balance (OR 0.76, 95% CI 0.67–0.85), and fit with personality/interests/skills (OR 0.64, 95% CI 0.53–0.77). Conversely, indicating a strong influence for content of the specialty increased the likelihood of entering neurology (OR 1.64, 95% CI 1.35–1.99). Role models/mentors and competitiveness of the specialty were not significantly associated with choosing neurology within the logistic regression analysis.

Discussion

The need to attract medical students to pursue a career in neurology is increasingly important as the burden of neurologic disorders increases for patients, caregivers, and society. Addressing this workforce shortage requires a deeper understanding of the reasons why medical students choose to enter or not enter the field of neurology. Barriers to this deeper understanding have included the lack of data informing medical student interest in neurology and the temptation to rely on presumed assumptions for these deficiencies in interest. This could result in a misguided effort to focus on incorrect factors believed to influence medical student selection of the specialty. Factors previously reported as most influential in medical student specialty selection include controllable lifestyles, specialty prestige, student debt, and the salary earning potential. Student sex, mentorship, and the scientific content of a specialty may also play a role.15,–,19 The best existing data compare students selecting primary care and those selecting specialties, while data on individual specialty choice are lacking. These data are difficult to extrapolate because, unlike other specialties, lifestyle and financial factors are considered the least motivating factors by neurologists at all levels in choosing their field of study.20 Similar findings were observed in this study.

Our results indicate that the percentage of medical students interested in neurology on entering medical school is similar to the percentage who choose neurology at graduation. However, the ranking of choice as a specialty drops at the time of graduation, from 8th of 17 at matriculation to 11th of 17 at graduation, with only 1 in 5 retaining their interest in neurology. This most likely reflects a lack of awareness of other specialties at matriculation given that the absolute percentage of students interested in neurology remains stable. Demographic variables do not influence the likelihood of choosing neurology, although, not surprisingly, a preexisting interest in neuroscience is predictive. Students who enter an MD/PhD program are more likely to enter neurology than other fields. While it is possible that this specific finding is biased by the popularity of graduate neuroscience programs, it further establishes a link between interest in neuroscience and choice of neurology as a field.

One prevailing hypothesis for the lack of growing interest in neurology is students' negative perception of neurology stemming from the complexity of the field. The perceived complexity of neuroanatomy and the difficulty in learning the neurologic examination may be compounded by a frequent failure to integrate clinically relevant content, specifically therapeutics, into the preclinical curriculum. The term neurophobia has been used to describe this fear of perceived complexity of the field.5 Hypothesized drivers of neurophobia include inadequate basic neuroscience and neuroanatomy courses, lack of integration of basic and clinical neuroscience content, and lack of access to neurologist mentors. The GQ does not specifically address the concept of neurophobia, but several proposed drivers of neurophobia may be potentially modifiable. Exposure to clinical neurology in a clerkship may be one of the measures to address neurophobia. In particular, the ratings of the preclinical neuroscience course and the neurology clerkship were strongly predictive of interest in neurology. The lack of neurology clerkship rotation (captured by NA in the GQ) predicted a significantly lower interest in neurology. Surprisingly, role models/mentors were not significantly associated with choosing neurology in our multivariable model, although it is possible that the influence of role models is reflected in the strength of the neuroscience course and clinical clerkship. Alternatively, role models/mentors may be important to students entering any field of medicine and not particularly to neurology.

Other variables outside of the medical school curriculum affected medical students' decisions to enter or not enter neurology. Students who indicated that salary expectation was a strong influencer were less likely to choose neurology. Although this may imply that those who chose neurology were more altruistic about the practice of medicine, it may also have meant that perceptions about noncompetitive salaries for neurologists were a barrier to choosing neurology as a field. However, that student debt did not predict student choice is reassuring that this was most likely not the case. Students who indicated that work/life balance was a strong influencer were also less likely to enter neurology. Given recent attention to burnout as a major problem in neurology, it is possible that students were aware of and concerned about this important issue. Several recent articles have explored the underlying causes for physician burnout, and the AAN is leading efforts to prevent and mitigate this issue.21,–,24

The results of the current study can be used a number of ways to improve the percentage of medical students pursuing neurology as a career. Assuming a causal link between medical school exposure to neurology and the student's career choice, focusing on excellence in the preclinical neuroscience course and a clinical clerkship may be valuable strategies. An optimal exposure to neurology can be ensured by incorporation of a mandatory clinical neurology experience into the medical school curriculum. In addition, placement of clerkship early in medical school curriculum will help inform the decision making at a more appropriate time for residency applications. Development of educational best practices and other resources for neuroscience course and neurology clerkship directors by the AAN and other stakeholders may also be helpful. Particular attention should be paid to fostering interest in students entering medical school with a neuroscience undergraduate degree, particularly those entering MD/PhD programs, to help sustain their interest in neurosciences and in neurology specifically. Focused mentoring programs for students with an interest in neurology early in medical school may also increase retention of students in the field.

Our results suggest that improving salaries for neurologists and reducing medical school debt, enhancing work/life balance, and demonstrating to students the availability of diverse career paths and associated benefits may also attract more students. Another way of addressing these concerns is for stakeholders to communicate the existing data on salary and wellness to students, emphasizing ongoing efforts to address these concerns. The salaries for neurologists have been steadily increasing over the past decade and compare favorably with salaries for other nonprocedural specialties.25 Neurology as a specialty has recognized burnout and wellness as a major priority, and the AAN has ongoing programs to prevent and mitigate burnout and to improve neurologists' wellness. The rate of burnout among neurologists, while high, is similar to that of other medical specialties.26

One limitation of the current study is that the AAMC surveys do not gather specific information on students' perceptions of neurology as a specialty. For example, the lack of awareness about the spectrum of career opportunities for neurologists or the extent to which antiquated notions about the lack of therapeutic options for patients with neurologic diseases may drive the decision making are not captured in these surveys. It may be that excellence in the clinical clerkship predicts student choice because well-run clerkships are able to showcase neurology as a therapeutic specialty with an impressive and evolving progress in treatment options. A better understanding of potential career pathways and lifestyles in neurology and recent therapeutic advances may make the specialty more attractive to medical students. Although mentorship was not identified as a decision driver, the availability of good role models who can effectively communicate these and other narratives to medical students at strategic times in their career may be particularly effective. Further support of existing student programs such as Student Interest Group in Neurology chapters and the development of new initiatives that help increase exposure to neurology earlier in medical school are some of the other strategies that can be pursued.

Another limitation of the study is that the data source used addresses only allopathic medical students in the US. Nearly half of neurology residents graduate from foreign medical schools, and many foreign graduates do not match. In addition, a minority of neurology residents graduate from US osteopathic schools. Different approaches may need to be taken to affect the number of foreign and osteopathic students entering neurology. It is likely that similar factors influence osteopathic students' career choices, and the approaches suggested by our results could reasonably be applied to this group. Different approaches may be necessary to increase interest in neurology among foreign medical school graduates. Further exploration of drivers of career choice in these groups is an important future direction.

Without the recruitment of higher numbers of medical students into the field of neurology, the gap between the increasing burden of neurologic diseases and the shrinking number of specialists in neurology caring for people with neurologic diseases is going to increase in the future. We hope that the findings from this study will help guide changes in the medical school curriculum and garner support for other measures proposed to increase students' interest of neurology as a medical specialty.

Author contributions

L. Gutmann: study design, interpretation of the data, drafting the manuscript. C. Cahill: study design, analysis and interpretation of the data, statistical analysis, drafting the manuscript. J. Jordan: analysis and interpretation of the data, drafting the manuscript. C. Gamaldo and V. Santini: study design, interpretation of the data, drafting the manuscript. I. Ali: study design, interpretation of the data. M. Soni: study design, gathering and interpretation of the data. R.B. Wilson and R. Said: study design, interpretation of the data. B. Czeisler: interpretation of the data. A.G. Smith: study conceptualization, interpretation of the data.

Study funding

This study was funded by the AAN and the Conrad N. Hilton Foundation (grant 20150396).

Disclosure

L. Gutmann has research funding from National Institute of Neurological Disorders and Stroke (NINDS)/NIH. C. Cahill is an employee of the AAN. J. Jordan has research funding from the Department of Defense, NIH, and Burke Foundation. C. Gamaldo receives royalties as a contributing author to Up-to-Date. V. Santini reports no disclosures relevant to the manuscript. I. Ali is a board member of the American Board of Psychiatry and Neurology and a consultant for Guidepoint Global, GLG Advisors, and Best Doctors. M. Soni reports no disclosures relevant to the manuscript. R. Wilson receives research funding from NIH. R. Said and B. Czeisler reports no disclosure relevant to the manuscript. A. Gordon Smith has research funding from NINDS and National Institute of Diabetes and Digestive and Kidney Diseases. Go to Neurology.org/N for full disclosures.

Acknowledgment

Chris Keran and Brandon Magliocco (AAN) provided statistical guidance. Sue Rodmyre, Lucy Persaud, and Maggie Rock (AAN) provided administrative support. This material is based on data provided by the AAMC. The views expressed herein are those of the authors and do not necessarily reflect the position or policy of the AAMC.

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.

  • ↵* These authors contributed equally to this work.

  • Editorial, page 786

  • Received September 19, 2018.
  • Accepted in final form January 3, 2019.

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