Neurologic and neuroscience education

Introduction

Neurologic disorders are among the most frequent causes of morbidity and mortality in the United States.^1,2 One out of 6 people in the United States presents with neurologic symptoms, yet there is only one neurologist available for every 18,000 people.³ By 2025, the current deficit between demand for neurologists and their supply is expected to worsen considerably.⁴ There is a pressing need for neurology education in graduate medical education given the aging population and its associated increased incidence of neurologic disorders.⁵ Notwithstanding, only 2.6% of graduating medical students will enter a neurology residency.^6,7 Thus, many patients with neurologic disorders will be treated by physicians without formal neurologic training. Patients will likely obtain their neurologic care from primary care providers who may not necessarily recognize the importance of consulting a specialist. Furthermore, a well-described fear of neurology, termed neurophobia,⁸ has been identified in medical student cohorts, residents, and among general practitioners.⁹ This article reviews current guidelines regarding neurologic education. The authors, who are members of the American Academy of Neurology (AAN) A.B. Baker Section on Neurological Education, contextualize the genesis and the negative consequences of neurophobia and propose key educational strategies designed to counteract it in order to mentor future generations of health care providers.

Previous reports and current guidelines

In response to the demand for physicians with adequate neurologic knowledge, the AAN Undergraduate Education Subcommittee published guidelines in 2002 for a Neurology Clerkship Core Curriculum.¹⁰ This guideline recommended that clinical neuroscience be offered in the first year of clinical training as a required clerkship. The rationale for this is that the curriculum revolves around the approach to the patient, with a focus on the core skills of history acquisition and the localizing value of the neurologic examination.¹¹ Since these recommendations were published in 2002, the number of programs with required neuroscience clerkships has increased. However, there is still a substantial number of medical schools that do not require a core neurology rotation or an elective.⁶

Although governing bodies such as the Liaison Committee on Medical Education (LCME) subserve an important role in the structure of medical school curricula, they are not meant to be prescriptive. Thus, it is often the primary responsibility of each medical school and its neurology department to ensure that instruction of the basic neurosciences and clinical neurology are given the appropriate dedicated time, emphasis, and financial support.¹²

Moreover, in 2013, the AAN Work Task Force report published an analysis that predicted a shortage of neurologists in the United States.¹³ One of the proposed solutions to address this problem was to train non-neurologist physicians more extensively in the specialty and to initiate this training with undergraduate medical education. They recommended that neurology education requirements be established in primary care specialties including internal medicine, family medicine, as well as emergency medicine.¹³ The predicted shortfall of neurologists necessitates that non-neurologist providers evaluate and treat patients with neurologic issues. Thus, neurologic education must be longitudinal commencing in medical school and continuing throughout a provider's career.

In terms of national standards for a clinical neurology experience during medical school, in 2000, the AAN, the Association of University Professors of Neurology, and the American Neurological Association endorsed standardized guidelines for a neurology clerkship core curriculum, which remain available online.¹⁴ The guidelines include specific recommendations for clerkship goals and objectives, content, personnel, and facilities, as well as methods of training and evaluation. The AAN website also published updated resources to be used in medical school curricula.¹⁵ Notwithstanding, there is a lack of updated guidelines and published standards in the context of more recent, broad medical school curricular changes. These include a move towards competency-based medical education, greater integration of basic science and clinical experiences, use of teaching strategies such as team-based learning, and increased use of educational technology. Moreover, there is a paucity of data regarding the effect of implementing these guidelines across medical schools. At the residency level, the Accreditation Council for Graduate Medical Education Specialty Program Requirements do not include standards for dedicated clinical neurology education in residency for several specialties that regularly interface with patients with neurologic diseases, such as internal medicine, emergency medicine, and family medicine. The fact that a standard for neurology clinical educational experiences is missing at the residency level might be due to lack of institutional commitment or resources. Irrespective of the root cause, this absence is rather surprising given how frequently these subspecialties encounter clinical neurology, and a negative effect on patient outcomes is inevitable given these providers' unfamiliarity with neurology. This increases the probability of diagnostic and treatment errors with ensuing morbidity and mortality at a much higher systemic cost.^16,17

Dissecting neurologic clerkship training

In a survey of neurology clerkship directors comparing medical school neurology clerkship training from 2005 to 2012, of the programs requiring neurology clerkships, there was a trend toward earlier, but briefer, exposure to neurology.¹⁸ An encouraging change was that more schools had their neurology clerkships in the third year in 2012 as compared to 2005 (56% vs 45%).¹⁸ The presence of a formal clinical neuroscience education during medical school was found to correlate with the number of students matching into neuroscience specialties.⁶ However, only 56% of medical schools required a neurology clerkship experience in 2014, which likely contributed to the statistic that only 2.6% of medical school graduates matched into a neuroscience specialty.⁶ In a 2015 update of the 136 LCME-accredited medical schools assessed, only 75% (102) of medical schools required a neuroscience clerkship.¹⁹

Moreover, neurology remains an elective course at some US medical schools despite the increasing neurologic disease burden. As of the 2016–2017 academic year, only 86% of American medical colleges had a dedicated neurology clerkship. In contrast, virtually all had dedicated clerkships for internal medicine, obstetrics and gynecology, pediatrics, psychiatry, and surgery.²⁰ In a survey of medical colleges from the prior academic year, 117 of 142 LCME-accredited schools reported a mean of 3.8 weeks of instruction in clinical neurology with the mode being reported as 4 weeks.^21,–,23 This figure has remained largely unchanged as compared to prior survey data from the 2006–2007 academic year. During that interval, medical schools reported a mean of 3.6–3.7 weeks of instruction in clinical neurology. Notably, the time dedicated to clerkships in internal medicine ranged from 10.9 to 11.3 weeks and 7.7 to 8.7 weeks for surgery.^21,–,23

Notwithstanding these improvements in American clinical neurology education, it is important to note that while 98% of adult neurology and 87% of child neurology residency positions matched, only 63% of positions were filled by US medical graduates.²⁴ If the medical system wishes to have more US medical graduates enter neurology, then additional efforts must be dedicated to mentoring US medical students to enter the neurosciences.

In Canada, a nationwide survey was conducted with internal medicine residents to identify the 20 most important topics among internal medicine residents and program directors.²⁵ The purpose of this survey was to create a 1-month clinical neurology curriculum designed to meet these expectations. Over 90% of residents opined that their competency in neurology was at or below average, supporting the hypothesis that inadequate neurology education is reducing the quality of care, possibly through underrecognition and mismanagement of neurologic disorders.²⁵ The self-perceived competency in neurology slightly increased among the internal medicine residents after the implementation of this curriculum.²⁵ These data suggest that the value in repeated, even if delayed, primary exposure to neurology is critical to ensuring quality of patient care.

Behind neurophobia: Key factors

Neurophobia, a fear of clinical neurology, is pervasive in medical education and in non-neurologic specialties. It substantially decreases the likelihood of achieving timely assessment and treatment of neurologic diseases, increases wait times for a limited pool of neurology specialists, and drains resources from those patients who ultimately truly need specialty care.⁸ Many trainees and physicians report a lack of confidence with clinical neuroscience.^8,26,–,28 In a survey of 258 medical students and house staff at a single US medical center, the percentage of trainees interested in brain-related specialties decreased from 51.7% in the first year of medical school to 27% in the fourth year.²⁹ Thirty percent of trainees identified neurophobia as the primary reason for lack of interest in brain-related specialties.^8,29 Reasons behind neurophobia range from limited patient exposure, to insufficient and poor bedside teaching, to the complexity of neuroanatomy.²⁸ Other factors cited include diagnostic complexity and the proper performance of a neurologic examination.^3,8,26 Neurophobia is common among medical students and represents a major barrier to addressing the projected shortage of neurologists required to care for an aging population.¹³ Its prevalence increased between the first and second years of medical school.³⁰ Thus, interventions to counteract this phenomenon must be mitigated by specific and timed educational interventions.

Beyond neurophobia: Key educational strategies

A required neurology clerkship is strongly correlated with graduating medical students matching into a neurology residency program.⁶ Thus, increasing neurology exposure and education during training is a viable solution³¹ (table). Addressing these concerns with novel educational models, such as facilitating clerkship goal setting, is associated with better adjusted standardized test scores, higher satisfaction, and greater tendency toward self-directed learning.³² Moreover, dedicating time to structured observation of the neurologic history and physical examination performed by faculty ensures that students develop comfort with neurology through meaningful exposure to key elements of the evaluation of neurologic patients.^33,34 In addition, mobilizing the front-line forces of neurology care delivery and education (i.e., residents) is a key component of the educational mission. In addition to didactic instruction, the day-to-day interactions between residents and medical students through shared patient care experiences can result in behavior modeling and professionalism. The challenges facing resident education are similar to those of medical clerks with opportunities to improve the neurology experience through faculty development programs, recognizing and rewarding educators, returning teaching to the bedside, and utilizing near-peer teaching and role modeling.³⁵

Training non-neurologists, both resident and attending physicians, in neurology is also of paramount importance. Given limited resources, neurology training should be enhanced in primary care programs, prioritizing some of the most prevalent neurologic disorders, such as stroke, headache, and dementia.³⁶ Training non-neurologists can be instrumental in receiving their support with basic neurologic care.³⁷ A study examining the reliability of the NIH Stroke Scale (NIHSS) performed by non-neurologists indicated that non-neurologist physician investigators could be rapidly trained to correctly perform the NIHSS in short order.³⁸ Furthermore, in a survey regarding training the future neurology workforce, neurologists opined that primary care physicians, nurse practitioners, and physician assistants could manage uncomplicated neurologic problems.³⁹ In addition, it has been reported that non-neurologists could be trained to diagnose epilepsy at a neurologist's level after exposure to only 20 patients with an appropriate mentor.⁴⁰

Given limited resources, much debate has taken place regarding the optimal methods that would accomplish neurology education of non-neurologic house staff. While the role of in-person, one-on-one interaction with direct observation of skills and feedback is important and irreplaceable, it is time-consuming, expensive, and therefore not viable. The use of educational technology in medical education may address this issue as described in a review.⁴¹ Both synchronous telecommunications and asynchronous learning methods have been employed with success in medical education.⁴² Although many electronic learning materials have been largely text-based, such as electronic books, materials using images and videos are also being utilized effectively. Podcasts and strictly audio materials have gained in popularity over the years, including “The Undifferentiated Medical Student” on the AAMC website⁴³ and “Everyday Emergencies” sponsored by Doctors Without Borders.⁴⁴ Live video conferencing may be used to host clinical conferences from the traditional morning report to the interview and examination of a patient in localization rounds. In this way, learning from demonstrated physical examination techniques at the bedside is possible for residents irrespective of location, provided the appropriate safeguards are in place. As with any new technique, objective outcomes measures are needed to ensure effective transfer of knowledge and skills. In this vein, a precurricular and postcurricular assessment tool, which reported a significant improvement in learner EEG interpretation skills in a variety of applications, has been created.⁴⁵

Electronic methods will therefore enable a larger target audience that can be tailored to the individual learner's level of expertise. Furthermore, the asynchronous nature of this methodology permits access across different schedules. In order to render neurologic thinking more accessible, creative-commons-licensed curricula have been developed to make the performance and interpretation of the neurology examination easier, thus empowering health care providers with diverse levels of neurologic expertise.⁴⁶ In the absence of a full neurology clerkship, medical schools can combat neurophobia by implementing eLearning resources to teach the neurologic examination and localization skills.²⁷ Podcasts and webinars can replace more traditional in-person clinical rotations. However, one potential unintended consequence of creating readily available, nontraditional educational materials for non-neurologists-in-training is that it may disincentivize medical schools and residency programs with already established neurology rotations from continuing to support in-person neurology experiences.

Additional strategies may involve the integration of basic and clinical approaches to neuroscience,⁴⁷ while other approaches may include team-based learning simulations and exposure to actual patients, thus making neuroscience more clinically focused.⁴⁸ This learning may be augmented in outpatient clinical settings in which students can observe that many neurologic patients have disorders that are amenable to treatment.⁴⁹