Abstract
Objectives To better understand the reasons medical students select or avoid a career in neurology by using a qualitative methodology to explore these factors, with the long-term objective of attracting more graduates to the field.
Methods In 2017, 27 medical students and 15 residents participated in 5 focus groups, and 33 fourth-year medical students participated in semistructured individual interviews. Participants were asked predefined open-ended questions about specialty choice, experiences in their basic neuroscience course and neurology clerkship, and perceptions about the field. Interviews were audio recorded and transcribed. We used a flexible coding methodology to generate themes across groups and interviews.
Results Four main analytical themes emerged: (1) early and broad clinical exposure allows students to “try on” neurology and experience the variety of career options; (2) preclerkship experiences and a strong neuroscience curriculum lay the foundation for interest in the field; (3) personal interactions with neurology providers may attract or deter students from considering the specialty; and (4) persistent stereotypes about neurologists, neurology patients, and treatment options harm student perceptions of neurology.
Conclusion Efforts to draw more students to neurology may benefit from focusing on clinical correlations during preclerkship neuroscience courses and offering earlier and more diverse clinical experiences, including hands-on responsibilities whenever possible. Finally, optimizing student interactions with faculty and residents and reinforcing the many positive aspects of neurology are likely to favorably affect student perceptions.
Glossary
- AAMC=
- Association of American Medical Colleges;
- AAN=
- American Academy of Neurology;
- CD=
- clerkship director;
- IRB=
- Institutional Review Board;
- MS1/2=
- first- or second-year medical student;
- MS4=
- fourth-year medical student
Fewer than 3% of graduating US medical students enter neurology, a proportion that has been static for years.1 The current neurology workforce shortage of 11% is projected to increase to 19% by 2025.2 While the global burden of neurologic disease grows,2,3 the neurology workforce has not.
Previous studies have explored students' choices of other specialties (e.g., internal medicine, emergency medicine, psychiatry) and identified predictive factors such as sex, lifestyle, “specialty archetype/personality,” perceived specialty prestige, and student experiences.4,–,9 Few studies have examined why medical students choose to enter neurology. Data from the Association of American Medical Colleges (AAMC) Matriculating Student Questionnaire and Graduation Questionnaire suggested that students were more likely to enter neurology if they rated their basic neuroscience course or their neurology clerkship as excellent, if they had an undergraduate major in neuroscience or psychology,10 or if they were interested in neurology on medical school matriculation.11
The objective of this qualitative study was to identify additional factors that influence whether medical students enter the field of neurology. Interviews and focus groups with current or recently graduated medical students were used to better understand the relationship between specific aspects of neurology and neuroscience exposure and career choice and to understand perceptions of neurology as a field. Career construction theory was used to interpret the results, which explains career choice as the culmination of a narrative of an individual's sequence of positions and perceptions that hold meaning and identify a person within his or her own mental self-construct.12
Methods
Study design
We performed both in-person focus groups and semistructured individual phone interviews. Focus groups were intended to understand trainee perceptions about neurology and career selection and feedback on American Academy of Neurology (AAN)–developed resources geared to trainees. Individual interviews focused on trainee perceptions of neurology and career selection.
Question development
Questions for both the groups and individual interviews were developed by a group of AAN member physician volunteers (J.T.J., L.G., C.G., V.E.S., I.A., M.S., R.B.W., R.R.S., B.M.C.), with guidance from an AAN staff researcher (C.C.). The physician authors generated ideas for questions based on experiences working with medical students, their own experiences selecting a specialty, and a thorough review of the existing literature. Specific questions were restructured and reworded to address potential bias (C.C.). Broad questions were asked first to allow trainees to share top-of-mind factors that influenced their specialty choice, while specific follow-up prompts were chosen as potentially relevant to selecting neurology as a field. Question guides are available on request.
Focus group sampling strategy
Five focus groups were conducted using convenience sampling (table 1). The first focus group contained first- or second-year medical students (MS1/2s) who were considering entering neurology. The second and third groups contained fourth-year medical students (MS4s); 1 group was planning to enter neurology residency, and the other was not. The fourth group included first- or second-year neurology residents, and the fifth included first- or second-year residents from another specialty. Four of the focus groups (neurology residents, both MS4 groups, and the MS1/2s) were held at the 2017 AAN Annual Meeting in Boston, MA, while the nonneurology resident group was held at AAN offices in Minneapolis, MN. Of the 4 groups held at the Annual Meeting, 3 were recruited by e-mailing a list of preregistered attendees. The MS4 nonneurology group was recruited with a snowball sampling strategy by contacting Boston area medical schools. The nonneurology resident group held in Minneapolis also used a snowball sampling strategy by distributing flyers to local hospitals and e-mailing residency program coordinators. The first 10 respondents for each group were accepted.
Characteristics of focus group participants
Individual interview sampling strategy
Using 2014 to 2016 data obtained from the AAMC Graduate Medical Education Track Resident Survey, we determined the approximate rate of medical students entering neurology from each US Liaison Committee on Medical Education–accredited institution relative to the overall class size. While there was no defined cutoff, schools at the bottom of the list, producing a lower percentage of neurology residents/fellows, were called low-frequency, and those at the top of the list, from which a high percentage of graduating medical students went into neurology, were called high-frequency. Working from the top and bottom of the list, we removed or added schools to ensure a balance of geographic, institutional ownership (private vs public), size, and clerkship timing (e.g., second year, third year, fourth year, or not required). Two of the high-frequency schools were excluded because authors held faculty positions at those institutions. The 4 Puerto Rican medical schools were excluded, as was the Uniformed Services University of Health Sciences, to control for findings that might be unique to those schools and their students.
We sought to recruit 3 students from each school according to level of interest: 1 student planning to enter neurology (high), 1 student who considered neurology but chose another specialty (medium), and 1 student who did not consider neurology (low). There were 2 exceptions to this: (1) inability to recruit a high-interest trainee from one of the low-frequency schools and (2) recruitment of an extra medium-interest student at a high-frequency school. The original framework included 12 schools and 36 students. Due to difficulty in recruiting students from schools without a clerkship and reaching data saturation, we ended data collection with 11 schools and 33 students. A list of students and their attributes is included in table 2. Interviewees were recruited by contacting Student Interest Group in Neurology programs and faculty at the selected institutions. Trainees were invited by e-mail to participate in an hour-long interview by AAN staff (M.R.). At institutions without Student Interest Group in Neurology chapters, the neurology clerkship director (CD) or other neurology faculty were individually contacted to forward the invitation to students.
Characteristics of individual interview participants
Data collection
The 4 focus groups held at the 2017 AAN Annual Meeting occurred between Friday, April 21, and Sunday, April 23. The group held in Minneapolis occurred on Tuesday, August 26, 2017. A single investigator (C.C.) moderated each of the 5 groups. Focus group participants received a $50 cash honorarium. Individual interviews were conducted May through November 2017. Interviews were conducted over the phone (C.C. and T.O.). Interviewees received a $50 Amazon.com gift card. All focus groups and interviews were audio recorded and professionally transcribed by Rev.com. Transcripts were reviewed and modified for accuracy (C.C. reviewed focus groups, and T.O. reviewed interviews). Identifying information was removed before analysis.
Analysis
We used a flexible coding methodology,13 a 3-step process that began with deductively indexing the data using both focus group and interview question guides as a framework. Indexing was followed by applying analytical themes based on observations from the initial review, which allowed inductive themes to emerge. The final step included conceptual validation by testing and refining theory generated from the analysis. We adopted a realist research paradigm,14 aiming to be objective in our approach while acknowledging that we cannot separate ourselves entirely from the research process. Analysis was guided by a career construction theoretical framework.12
Transcripts were coded and organized with NVivo 11 software (QSR International, Victoria, Australia). For the focus groups, C. Cahill performed a basic thematic analysis across the 5 groups. For the individual interviews, C. Cahill and T. Ostendorf used an iterative process to develop a thematic content-based coding scheme. In the first step, both researchers separately coded the first interview, generated separate codebooks, and performed a line-by-line comparison of the coding scheme until consensus was reached and consolidated into 1 codebook. In the second step, the researchers each coded 2 separate interviews before double-coding another (the sixth) interview, which was again compared line by line to ensure that both researchers coded in a similar manner and to modify the codebook as needed. This process was repeated (double-coding and line-by-line consensus) on the 15th and final (33rd) interviews, and no further refinements to the codebook were needed. A physician author (J.T.J.) reviewed the coding of the first interview and agreed with the scheme. Once coding was complete, queries were run to analyze themes and to look across attributes such as interest level, clerkship timing, and school rate. Major themes and subthemes were summarized with quotations to illustrate the themes.
Standard protocol approvals, registrations, and patient consents
As a privately funded organization, the AAN is not subject to the Common Rule and typically does not seek Institutional Review Board (IRB) approval to conduct focus groups and interviews. These interviews and focus groups were conducted by AAN staff before approval from an IRB. The physician authors received deidentified data from the AAN, which were then reviewed by the IRB at the University of Utah and considered IRB exempt (IRB No. 00105172).
Data availability
Because formal written consent was not obtained from participants and the raw data are too identifiable, the AAN will not make the raw data available to researchers. However, internal AAN reports with deidentified data are available on request.
Results
Forty-two trainees participated in the 5 focus groups, and 33 MS4s participated in individual interviews (table 1). Focus group discussions lasted ≈1 hour for each group. Interview length ranged from 20 to 60 minutes. Demographic characteristics such as age, sex, and race/ethnicity were not collected from participants.
Four main analytical themes were extracted from the data: curriculum and preclerkship experiences (table 3), clinical exposure (table 4), personal interactions (table 5), and perceptions (table 6). Main themes and subthemes are described in subsections below; subthemes and deidentified illustrative quotes are included in tables 3 through 6.
Curriculum and preclerkship experiences subthemes and illustrative quotes
Clinical exposure subthemes and illustrative quotes
Personal interactions subthemes and illustrative quotes
Perceptions subthemes and illustrative quotes
Curriculum and preclerkship experiences
Interest in basic science content
Most trainees described their basic neuroscience courses as intellectually stimulating and full of problem-solving. A frequently used positive word to describe the course was “interesting.”
While some trainees entering neurology enjoyed the detailed basic science lectures, others lost interest due to the amount of specific detail. This was especially true when the basic neuroscience concepts seemed disconnected from what they were expected to know clinically or when they were unable to grasp a global perspective of how the brain functions.
Clinical correlations
Trainees unanimously agreed that clinical correlations with the basic neuroscience course are important in stimulating specialty interest. In addition, a clear difference between high- and low-frequency schools emerged. Trainees from high-frequency schools consistently described strong clinical correlations in their basic neuroscience course. Low-frequency schools were mixed; half of the trainees from low-frequency schools mentioned high levels of clinical correlation, whereas half described a paucity. Within the same school, perception of clinical correlation strength or proportion of clinical vs basic science faculty did not differ between students who did and those who did not choose a career in neurology.
Faculty influence
All schools incorporated a mix of basic researcher and clinical faculty lecturers in the preclerkship neuroscience course. Three of the 5 high-frequency schools were directed by clinical faculty vs 2 of the 6 low-frequency schools. Most trainees did not give much consideration to whether the course director was a clinician or basic science researcher, and many struggled to recall this information. However, some trainees expressed a preference for clinical faculty over basic science research faculty, citing clinicians' ability to bring in first-hand clinical experience.
Specialty interest group activities
Students often became involved in student interest groups early during their medical school experience and stayed with that interest group regardless of whether they decided to enter that specialty. Popular and engaging events included speaker panels, hands-on activities, free food, social gatherings/networking opportunities, and patient/case presentations. While students generally enjoyed student interest group activities, not all considered them to be the most useful way to learn about specialties and career interests.
Clinical exposure
Clinical exposure appeared to be the most important factor driving trainee career selection. Clinical exposure allowed trainees to either envision or experience the day-to-day experiences of working in a specialty. This factor was mentioned by all trainees and described extensively by many.
Doing vs seeing
Experiences were described as especially important, more so than shadowing. Examples of clinical experiences included interacting with patients, performing procedures (e.g., nerve conduction studies and lumbar punctures), presenting findings to residents and attendings, creating a care plan for patients, and feeling like a contributor to the care team.
Breadth of exposure
The type of clerkship settings that trainees experienced varied greatly, both within and across institutions. Students at most institutions had the ability to choose between various types of neurology settings (e.g., outpatient clinics, consult service, inpatient team, and neuro-critical care unit). Those with an interest in neurology generally picked a greater variety of settings, effectively exposing them to an increased variety of patient populations and subspecialties within the field.
Timing of specialty choice
Even though some students made their specialty selection as early as the second year of medical school and others made their decision as late as the fourth year, the majority of participants confirmed their choice of specialty in mid to late third year. Those who waited until the fourth year to decide on their specialty described wanting to have additional clinical experiences before making their decision. This was especially true of students who did not have the opportunity to rotate through a neurology clerkship in the third year.
Absence of a clerkship
As much as the timing of the clerkship was critical to choosing a career in neurology, access to a neurology clerkship was even more crucial. There was only 1 trainee entering neurology from an institution without an adult neurology clerkship. This individual used elective time during the third year to rotate through neurology clerkships at other institutions through the AAMC's Visiting Student Application Service.
Personal interactions
Providers affiliated with a specialty greatly affected students' opinions of the specialty. Neutral or negative interactions tended to steer students away from a specialty, while positive interactions attracted them. These interactions generally fell into 4 subthemes: mentors, faculty and residents, CDs, and formal/informal advising. Categories often overlapped such as CDs or faculty serving as mentors.
Mentors
Across an array of specialty interests and institutions, trainees generally considered mentors to be an important influence on their specialty choice. Among the 5 students entering neurology from low-frequency schools, all cited mentors as having a positive influence on them. Mentors were also an important factor for those students entering neurology from high-frequency schools and for those who considered but did not enter neurology. Not all mentors were within the same field that the trainee ultimately selected. For example, 2 students who decided on internal medicine cited mentors within neurology, whereas 1 student who selected neurology cited a mentor within neurosurgery.
Faculty and residents
Interactions with neurology faculty left a considerable impression on trainees, for better or for worse. Most trainees from high-frequency schools rated their neurology faculty in a positive manner, regardless of specialty interest. Trainees entering neurology from low-frequency schools also reported positive interactions with neurology faculty. Trainees from low-frequency schools who did not enter neurology tended to have mixed opinions about neurology faculty and mentioned more negative interactions or perceptions (e.g., residents yelling, faculty who “hated themselves and their life”) than those entering neurology or those from high-frequency schools.
Interactions with residents mirrored the interactions with faculty. If the faculty at an institution were well liked, then trainees generally reported positive interactions with residents from the same institution. Likewise, if faculty interactions were up and down, resident interactions tended to be mixed as well. Although resident interactions tended to carry less weight than faculty ones, they still influenced trainees' opinion of the clerkship and the specialty.
Clerkship director
Some students did not interact with the CD, but most did. For those who had more extensive interactions, trainees praised their neurology CDs regardless of whether they intended to enter neurology. Although more trainees from low-frequency schools reported limited interactions with their CDs compared to trainees at high-frequency schools, they did not mention if it negatively affected their experience in the neurology clerkship.
Formal and informal advising
Students at every institution mentioned that deans and other formal academic advisors were available as a career resource. While they were helpful for general queries, most students did not turn to these individuals to guide them in choosing a specialty. However, informal advisors were frequently mentioned as helping trainees select a specialty. Classmates, residents, faculty, CDs, program directors, research mentors, clinicians outside of their specialty of interest, and clinicians from other institutions were all considered influential resources in career choice.
Perceptions
Focus group participants were asked to draw a typical neurologist at work, with the goal of encouraging discussion and to reveal perceptions about neurologists and their patients. Because individual interviews were conducted over the phone, those participants were instead asked to list adjectives about neurologists rather than draw. While some of the perceptions were consistent across focus groups and individual interviews, the drawings generated a much richer discussion of stereotypes about neurologists.
Neurologists
Several of the typical neurologist drawings have been included in this report (figure). Almost every trainee drew or described a neurologist holding a reflex hammer. Although it was not the case in every drawing, trainees envisioned the typical neurologist as older and male. Trainees in each group were quick to point out that they knew the field was not limited to male neurologists, but they still had that image in their mind. Some participants drew female neurologists to emphasize the growing number of women in the field or because they wished there were more. In addition to being older and male, the typical neurologist was described by focus group participants as being “nerdy,” “happy,” “intelligent,” “interested in research,” “introverted,” “passive,” “passionate,” “enjoys teaching,” and bowtie-clad.
Trainee drawings of a typical neurologist by each of the following: (A) resident physician in neurology, (B) resident physician in a nonneurology specialty, (C) medical student planning to enter neurology, and (D) medical student not planning to enter neurology. The prompt for the task was the following: “Please take 3 minutes to draw a picture of a typical neurologist at work. You can draw what kinds of tools they might use, items they might have on them, and where they might be or what might be surrounding them at work. If you would prefer not to draw, then please list 10 words to describe a typical neurologist at work.”
Interviewees were asked to use 3 adjectives to describe the neurologists they have encountered. The most commonly associated word, regardless of institution or specialty choice, was “intelligent.” Other variations on intelligent included “brainy,” “smart,” “cerebral,” “knowledgeable,” and “thinker.” Trainees entering neurology tended to use more positive adjectives such as “brilliant” and “warm.” Those trainees not entering neurology also frequently used positive adjectives, mixed with neutral descriptive words such as “detail-oriented” and “teachers.” Those not entering neurology and particularly trainees from low-frequency schools described neurologists as “quirky” or “peculiar.” Some described the quirky stereotype as endearing, but for some it was not.
Neurologic patients
As part of their drawings/descriptions, some focus group participants drew what they considered typical neurology patients. Many drew patients comatose or in wheelchairs, and when asked to describe a typical neurology patient, participants used words like “older,” “complicated,” “frustrated,” “skeptical,” “scared,” “shocked,” “deteriorating,” “misunderstood,” “disabled,” and “confused.”
Interviewees were asked to use 3 adjectives to describe the neurology patients they have encountered. Three trainees struggled to generate words and opted not to respond. Of the 30 who did, a mix of positive and negative adjectives were used. Trainees entering neurology tended to use positive words like “resilient” and “rewarding.” This was opposed to those not entering neurology, who tended to use more negative words like “chronic” and “heavy.” Two words used by trainees across specialty interests and institutions were “interesting” and “complex.”
Treatments
Trainees entering the field of neurology perceived more treatment opportunities than those who considered it but chose another specialty, and much more so than those who did not consider neurology at all. Virtually all trainees entering neurology had an optimistic view of current treatments. Furthermore, several noted outdated treatment perceptions among their peers. For those who viewed neurology as having insufficient treatment options, this factor was often described as a considerable turnoff.
Research
While trainees were divided about treatment options, virtually all agreed that neurology is full of research opportunities. For those entering neurology, the research opportunities were enticing and frequently brought up as a reason to enter the specialty.
Fit
Career fit is the concept of harmony between one's self, others practicing in a given specialty, and the content of that specialty.15 Participants had a different mix of factors that influenced their decisions (e.g., lifestyle, values, friend or family member affected by a disease, length of residency, work/life balance, opportunities to subspecialize, earnings), but it ultimately came down to fit and the trainee's perceived fit in that field.
Discussion
Specialty decision is a complex choice, influenced by many factors in both medical school experiences and personal experiences. Our research focused on the medical school experience, hoping to reveal actionable items that will influence more students to enter the field of neurology. In this exploration, we uncovered 4 main analytical themes that influence neurology career selection: (1) curricular and preclinical experiences, (2) clinical exposure, (3) personal interactions, and (4) perceptions of the field.
The most critical experience for a medical student choosing a career in neurology stems from exposure to the field of neurology. The timing thereof has been the topic of national medical school curriculum discussion; indeed, the importance of an early exposure was emphasized in these findings, as well as the detrimental effects of late exposure when neurology was not a respondent's chosen field. Equally important were the underlying characteristics of individual neurology rotations. Students were more likely to pick neurology for a career if they had wide-ranging clinical experience during their rotation (i.e., outpatient and inpatient care) and if they were given meaningful responsibilities. Taken together, these findings suggest that students who have an early, hands-on, and broad exposure to neurology—including inpatient and outpatient settings, adult and pediatric—may more readily try on roles and imagine themselves in a similar career.12,15,–,17
The structure and educational environment of the neuroscience curriculum also strongly affect whether a medical student chooses neurology. Given that the basic neuroscience course is often the first opportunity for students to learn about nervous system function (and dysfunction), it is intuitive that this early exposure could imprint an overall view of the field. Students specifically underscored an imposed barrier to intellectual curiosity put in place by neuroscience curricula involving minimal clinical correlations. In contrast, the inclusion of real patients in didactic lectures or a focus on therapeutics for learned pathologies brought a recognition that neurology is a field of active treatments. The labeling of neuroscience as “complex” or “challenging” largely turned students away from the field rather than attracting them to the “puzzles” that are often touted with a sense of pride, consistent with prior survey-based studies on this topic.18,–,21 Leveraging these experiences to support career interest in neurology was a key finding and congruent with the explanation in career construction theory of affecting interests on career decisions.12
Positive interpersonal interactions with neurologists were also an important factor in students choosing a career in neurology. Career construction theory emphasizes the importance of role models and mentors for individuals making career decisions. When considering careers, individuals often consider interactions with individuals affiliated with the career paths in question and whether they can imagine themselves fitting in with the personalities, work style, and values of those mentors and role models.12,22 The images in the figure visually demonstrate how the presence or quality of such interactions may contribute to implicit bias regarding neurologists. We recognize that the images shown may be uncomfortable for some readers, but the implicit bias they reflect must be recognized and thoughtfully addressed with education and broader exposure to the full spectrum of neurologic practice to most accurately represent neurology as a field to potential future neurologists and colleagues entering other medical specialties.
Mentorship was a primary component of interpersonal interactions that affected student career decisions. While neurologist mentors were often affiliated with students who chose neurology, a minority of students cited mentors from fields other than their final specialty choice who played an important role in their decision. This highlights the importance of educating colleagues in other specialties about advances in neurology to avoid detraction from student interest by communication of outdated information. It is also worth noting that a minority of students implied a lack of mentorship available to them. This confirms previous work demonstrating that focused mentorship is crucial and effective in developing neurology career interest,23 although such mentorship is not equally available in all schools. Therefore, this information presents an opportunity for innovative mentorship strategies for bridging distances and increasing diversity of mentors based on personal and career attributes; we want students to be able to envision themselves as neurologists and to break down stereotypes.
Another lesson learned is the lasting effect of negative interactions with faculty and residents. Some students cited a perceived unhappiness among neurology residents and faculty, and even a sense of disinterest and punishment coming from residents in some institutions. There was also awareness of the risk of burnout within neurology, including among neurology trainees, relative to other specialties.24,–,26 In addition to ongoing local and national programs focusing on physician well-being and burnout prevention, programs may consider an educational strategy to emphasize the importance of well-being within our field, to reinforce the importance of positive interactions between neurology residents and medical students, and to regularly obtain feedback on those interactions during or after clerkships.
This study offers several strengths regarding neurology career choice. First, to the best of our knowledge, this is the largest qualitative study on this topic to date. We strengthened the reliability of our data through the use of both focus groups and individual interviews and used trained interviewers. The data acquisition and analysis were strengthened by our investigator reflexivity (neurologist and nonphysician researcher collaboration), by the use of career construction theory, and through incorporation of a flexible coding methodology with iterative theme development. Finally, the credibility of our findings was demonstrated through confirmation of previously published themes within this topic from multiple data sources.
This study is not without limitations. Both Puerto Rican and osteopathic medical schools were excluded, yet these students also contribute to the neurology workforce pipeline. We struggled to recruit trainees from schools without a neurology clerkship and leaned on neurology faculty and students active in neurology interest groups to recruit their peers, introducing the potential for bias. We also relied on convenience sampling for focus groups, recruiting trainees who were attending the AAN Annual Meeting for 3 of 5 groups (an opportunity pursued by a select group of trainees that may not be representative of all who are interested in a career in neurology). Focus groups were run by AAN staff, which could have led to students using impression management, biasing responses. Several students independently described their child neurology clinical rotations, but we did not ask if this experience was an option for all students. As a result, these findings may not accurately reflect all US medical students and may contain perspectives that are favorable to adult neurology. Although career theory was invoked as part of the analysis, the question guides for both focus groups and interviews were constructed on the basis of quantitative factors previously shown to affect whether students choose a career in neurology. Finally, the relationship between preexisting levels of interest in neurology with perceptions of course quality and clerkship opportunities could not be determined on analysis. Future studies could expand sampling to include students from schools in Puerto Rico and osteopathic schools, to include a more randomized selection of medical schools, to use non-AAN staff focus group leaders, to expand focus to include child neurology, and to implement career theory into the construction of the question guides.
Study funding
This study was funded by the AAN and the Conrad N. Hilton Foundation (grant 20150396).
Disclosure
J. Jordan has research funding from Department of Defense, NIH, and the Burke Foundation. He receives royalties from Elsevier and has received honoraria from the AAN for course planning. He performs paid consultation for Recursion Pharmaceuticals and the Neurofibromatosis Network and unpaid consultation for SHEPHERD Foundation. C. Cahill and T. Ostendorf are employees of the AAN. L. Gutmann has research funding from National Institute of Neurological Disorders and Stroke (NINDS)/NIH. A. Navarro reports no disclosures. C.E. Gamaldo receives royalties as a contributing author to Up-to-Date and a paid consultant for Jazz Pharmaceuticals. V.E. Santini has received grant funding from the AAN and the Huntington's Disease Society of America; institutional salary support from NIH/NINDS Pacific Northwest Udall Center, the Michael J. Fox Foundation for Parkinson's Research, and NIH/National Institute on Aging Stanford Alzheimer's Disease Research Center; clinical trial support from Biogen, Inc, Roche/Genentech, Inc, Insightec, and the NINDS; and consultation feed from Guidepoint Global, Abbvie, and Neurocrine. I. Ali is a board member of the American Board of Psychiatry and Neurology and consultant for Guidepoint Global, GLG Advisors, and Best Doctors. M. Soni reports no disclosures. R.B. Wilson receives research funding from the NIH. R.R. Said and B.M. Czeisler report no disclosures. M. Rock is an employee of the AAN. A.G. Smith has research funding from the NINDS and National Institute of Diabetes and Digestive and Kidney Diseases. Go to Neurology.org/N for full disclosures.
Acknowledgment
The following AAN staff members contributed to this manuscript: Carol Rheaume provided guidance on the interview framework, and Sue Rodmyre and Lucy Persaud provided administrative support.
Appendix Authors
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 as first authors.
- Received April 29, 2019.
- Accepted in final form February 21, 2020.
- © 2020 American Academy of Neurology
References
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