Abstract
Despite increased neuroscience interest at the undergraduate level, a significant shortage of neurologists in the United States exists. To better understand how to generate more interest in neurology, specifically at the undergraduate level, we conducted an anonymous cross-sectional online survey comprising 1,085 undergraduates in either neuroscience courses or majoring/minoring in neuroscience from across the United States to better understand their clinical neurology experiences and perspectives. The survey quantitatively and qualitatively assessed students' clinical neurology exposure inside and outside of the classroom, research experiences, and career goals. Students were from a broad spectrum of undergraduate institutions (public research university [40.8%], liberal arts college [29.7%], and private research university [29.0%]). Most students (89.9%) were looking to pursue graduate studies; 56.9% reported wanting to be a physician, and 17.8% expressed interest in obtaining an MD/PhD. Of importance, students reported first exposure to neuroscience at age 16 years but felt that they could be exposed to neuroscience as early as 13 years. Half (50.5%) decided to major in neuroscience before college, and a quarter (25.6%) decided to major in their first year of college. Despite high interest in clinical neurology exposure, less than one-third of students had spoken with or shadowed a neurologist, and only 13.6% had interacted with clinical neurology populations. Only 20.8% of students felt volunteer and internship opportunities were sufficiently available. Qualitative results include student perspectives from those who did and did not work with a neurologist, describing how they were or were not able to obtain such opportunities. We discuss translating the survey findings into actionable results with opportunities to target the undergraduate neuroscience interest to improve the neurology pipeline. We describe existing programs that could be integrated into everyday neurology practices and new approaches to learning and training to help leverage the significant undergraduate neuroscience interest. We also raise questions for further research, including exploring (1) how students learn of neurologic conditions/expand their knowledge about additional neurologic conditions, (2) whether qualitative investigation of the experiences of neuroscience undergraduates at specific institutions might provide an additional insight, and (3) systems to maintain interest in neuroscience/neurology as students enter medical school.
A significant shortage of US neurologists remains despite exponential growth of neuroscience interest and majors at the undergraduate level.1,2 The neuroscience major is the fifth most common undergraduate major for medical students (3.5%).3 Being a neuroscience major in the undergraduate years increases the likelihood of a career in neurology; at the time of medical school graduation, 13.3% of those entering neurology were undergraduate neuroscience majors compared with 4.5% of those not entering neurology.4
However, only 2.7% of medical students indicate an interest in neurology at the time of medical school matriculation.4 This is below internal medicine or one of its subspecialties (11.2%), pediatrics (8.5%), surgical subspecialties excluding neurosurgery (7.7%), general surgery (6.2%), and emergency medicine (5.8%).4 Given the high number of neuroscience majors today and the few students entering medical school with interest in neurology, a disconnect seems to exist between interest in the undergraduate neurosciences and the field of neurology. Although personal interactions with neurology professionals can attract medical students into the specialty,5 it is unclear what clinical neurology exposure undergraduates receive.
Learning From Undergraduates Studying the Neurosciences Through a Survey
To understand this gap and methods to improve the neurology pipeline, we conducted an anonymous voluntary cross-sectional study of undergraduates across the United States interested in the neurosciences to examine their experiences. We assessed exposure to and interest in neurology content, along with students' interests in and attempts to gain clinical and research experiences in neurology.
Participants
We reached out to Faculty for Undergraduate Neuroscience6 and faculty from schools with undergraduate neuroscience majors previously identified7 to distribute the anonymous REDCap survey link to students in neuroscience courses or majoring/minoring in the neurosciences. To determine a response rate, all faculty/administrative persons who helped disseminate the student survey were asked to complete a brief faculty survey using Qualtrics to understand the number and method of student survey distribution (i.e., a course, an advisory group, and a major listserv). We asked students from whom they received the survey to match responses to survey distributor. The survey was distributed between October 21, 2020, and December 22, 2020, and there was a snowball effect (eFigure 1, links.lww.com/WNL/B735).
Survey Development and Remuneration
An iterative approach was used for survey development with multiple rounds of edits based on feedback from different stakeholders, including 1 board-certified neurologist (M.T.M.) who had mentored nearly 30 undergraduates, 5 undergraduate students, and 4 undergraduate neuroscience faculty. The survey was then reviewed by the American Academy of Neurology (AAN) Member Insights team for their additional input. Survey topics included early/initial interest in the neuroscience major, goals/skill acquisition within the neuroscience major, experiences obtaining research and clinical opportunities, feedback on the neuroscience curriculum, and future/career goals.
Students who completed the survey were offered a letter of recognition from the AAN, entry into a sweepstakes offering 1 of 5 $100 Amazon.com gift cards, and access to a website with additional neuroscience and clinical neurology opportunities.
Standard Protocol Approvals, Registrations, and Patient Consents
This study was approved by the NYU Langone Health Institutional Review Board, and there was a waiver of signed consent.
Data Analyses
We conducted descriptive analyses using SAS software, version 9.4, to determine response frequencies, means, standard deviations, and confidence intervals for estimated proportions and odds ratios. Likert scale responses (1–5) were averaged. We conducted sensitivity analyses to test for differences in responses across distribution channels. Categorical variables were analyzed using the χ2 test and continuous responses using the Kruskal-Wallis test to note any differences in participant responses between those students who received the survey from identified faculty distributor and were labeled as matched, those students who completed the survey without an identified faculty member distributor and labeled as unmatched, and those who provided no information and were unidentifiable. Post hoc analyses were conducted to determine differences in race/ethnicity in key survey responses. We also conducted qualitative analyses using grounded theory8 using both Microsoft Excel and NVivo11.
Data Availability
Anonymized data not published within this article will be made available by request from any qualified investigator.
Results
Participant Recruitment and Demographics
Table 1 reveals the Participant Demographics and Institutional Characteristics. In total, 6,382 identified students were e-mailed the survey by their undergraduate neuroscience department, with an additional unidentified number of students e-mailed the survey using the snowball effect (Table 1). A total of 1,085 participants completed the student survey, with 973 of them having received the survey from identified faculty (89.6%), leaving 10.4% participation from snowball effect. Responses that included a distribution source as blank, unintelligible, or designating a name that had not completed our Qualtrics survey were not included in our response rate estimation; the response rate of the students who received the survey from identified faculty was 15.2% (973/6,382).
Participant Demographics and Institutional Characteristics
Most undergraduates were female individuals (76.1%), White (63.0%) or Asian (25.5%), and either juniors or seniors (70.1%) (Table 1). These demographics reflect that female individuals comprise the majority of undergraduate neuroscience program graduates and that White, followed by Asian/Pacific Islander racial groups, comprise a significant portion of graduates.9 Although respondents mostly attended urban institutions (72.3%), the geographic distribution was throughout the United States, with all 5 regions represented (Table 1). Most students were looking to pursue graduate studies (89.9%; 972/1,081), with many hoping to be a physician (56.9%; 614/1,079). Of those interested in graduate studies, nearly 1 in 5 (17.7%; 172/972) were seeking a combined MD/PhD.
Neuroscience Experiences, Exposure, and Reasons for Pursuit
Many students surveyed were either currently majoring or planning to major in neuroscience (93.6%) (Table 2 and eTable 1, links.lww.com/WNL/B735). Average first exposure to neuroscience was age 16 years, although students felt it could have been as early as 13 years. Most (76.1%) decided to major in neuroscience by the end of their first year of college (50.5% before entering college and 25.6% during their first year of college) (Table 2). Top reasons for majoring in n neuroscience were interest in the field, high school (HS) exposure, and future career interest (Table 2). Of those who had decided to pursue the neurosciences before entering college, qualitative analyses showed that their decision was based on (1) diverse academic and practical interests; (2) being inspired by academic sources; (3) life experiences; and (4) previous neuroscience exposure through enrichment activities or research involvement (eTable 1).
Quantitative Responses to Interest in Neuroscience and Neurology
We also further analyzed those with a neuroscience major vs those who were not currently or planning to major in neuroscience (6%) (eTable 2, links.lww.com/WNL/B735). The former was more likely to have gained clinical neurology experiences and more likely to have experience conducting neuroscience research, with p < 0.001. Additional exposures and experiences to neurosciences were greater in those with the major compared with those without (e.g., spoken to a neurologist, opportunity to interact with neurology patients, and opportunity to shadow a neurologist), although the small sample size (<20 in each block) limits the ability to observe statistical significance in the comparisons.
Neuroscience Curriculum
Most participants felt their neuroscience curriculum gave them the opportunity to engage with scientific literature (81.7%) and human subjects clinical research (73.2%), typically through instructor-led class discussion (59.9%) (Table 3). Students reported that neurologic diseases were covered in their major coursework (71.2%), although basic cellular biology (82.9%) was the most common topic covered in major coursework (Table 4).
Quantitative Responses Regarding Neuroscience Curriculum and Coursework
Codes of Examples Provided by Students for How They Gained Exposure to Neurology Opportunities (Number in Parentheses Indicates Number of Codes)
Clinical Neurology Interest and Experiences
There was a substantial interest (on the 1–5 Likert scale) in working with neurologic patient populations (4.69 ± 0.68), shadowing a neurologist (4.69 ± 0.76), and gaining clinical neurology experience (4.66 ± 0.74), with interest in a wide array of neurologic conditions (Table 2). Yet less than one-third (28.8%) of students had spoken with neurologists about career experience (Table 2). Most (93%) of those who had not spoken with a neurologist were interested in doing so. Of those who had spoken with a neurologist, 95.5% reported the interaction was helpful in characterizing the career of a neurologist. Although 43% had attempted to gain clinical neurology experience, most of those who tried (64.6%) were unsuccessful in gaining this experience. Twenty-five percent of all respondents had an opportunity to shadow a neurologist/neuropsychologist and even fewer had the opportunity to interact with neurology patient populations (13.6%). Most students (87.3%) wanted to attend neurology conferences.
We conducted additional analyses comparing those who had spoken to a neurologist about career experiences with those who had not and those who had attempted to gain clinical neurology experiences with those who had not (eTable 3, links.lww.com/WNL/B735) and found that those with exposure/experiences were younger when first exposed to neuroscience, more likely to cite physician as a career goal, and more likely to be upperclassmen.
Clinical Neurology Opportunities
Only one-fifth of students (20.8%) felt that there were sufficient neuroscience volunteer and internship opportunities available for neuroscience majors. Regarding usefulness of different resources in finding opportunities, 35.2% reported that personal connections were the most useful, followed by their professor (30%) and major advisor (24.7%). Students felt their campus website was the least useful resource. A variety of resources were used for successfully obtaining clinical neurology opportunities (Table 4). A multitude of barriers were identified for not obtaining or pursuing clinical neurology experiences, for example, lack of resources and disruptions due to COVID-19 (eTable 4, links.lww.com/WNL/B735).
Neurology Research Experience
Although there was also substantial interest in participating in clinical research (4.56 ± 0.81 on the 1–5 Likert scale) (Table 2), with two-thirds (66.7%) reporting interest in conducting patient-centered clinical research (Table 5), just less than half had experience conducting neuroscience (42.9%) or non-neuroscience (34.5%) research (Table 3). Only 24.4% of those who conducted research conducted patient-centered clinical research. Top barriers to neurology research experiences were finding an open/available research position (76%) and finding laboratories with a matching interest (49.7%); additional barriers are listed in Table 5.
Quantitative Responses About Students' Research Experience(s)
Significant Findings by Race
Approximately half (52%) of the students who identified as White only, selected physician as their career goal compared with 62% of non-White/multiracial students (OR = 0.66; 95% CI:0.52–0.85; p = 0.0009) (eTable 5, links.lww.com/WNL/B735). Asian students most frequently reported physician as their career goal (65%; 95%CI: 59%–71%). White students were significantly more likely to have had opportunities to engage with scientific literature than their non-White peers (84%, OR = 1.38; 95% CI: 1.01–1.88) and were less likely to have experience conducting neuroscience research (40%, OR = 0.77; 95% CI: 0.60–0.98). Conversely, engagement with scientific literature was least common in Asian students with 77% (95% CI: 72%–82%) having had the opportunity and were the most common racial group to report having previous neuroscience research experience (49%; 95% CI: 44%–56%). There were significant differences (p = 0.0363) between the students' institution of latest research, with White students more frequently doing research at unaffiliated hospitals (difference of 4%, 95% CI 1.0%–6.7%) and less frequently doing research at an outside institution (difference of 4.7%, 95% CI 0%–10.0%).
Key Findings
The key findings of the national survey were as follows: (1) students' strong interest in neurology but limited opportunities of exposure to neurologists, clinical neurology experiences, and clinical research; (2) the average age of first neuroscience exposure was 16 years, with half of the students deciding on a neuroscience major before entering college; and (3) most students aim to pursue MD, PhD, or MD/PhD careers. These findings support the importance of bridging undergraduate neuroscience studies with clinical neurology opportunities to strengthen the neurology pipeline. Key strategies to target this approach include the following: (1) early exposure to neurology; (2) inclusion of clinical neurology information in undergraduate and HS curricula; (3) increasing undergraduate exposure to neurologists and clinical neurology; (4) organizational support of undergraduate interest.
Early Exposure to Neurology Before Entering College
Half of the students reported being exposed to and deciding to major in neuroscience before entering college, and many stated that they would have preferred even earlier exposure. Efforts to introduce neurology to younger students, that is, middle and HS students, may engage students at critical times in their development and increase their likelihood for choosing neurology as a career. The Neuroscience Pipeline Program at the University of Pennsylvania is a successful program in which medical students, guided by neurology residents and fellows, teach undergraduate students, who then instruct local HS students in topics related to neuroscience and neurology.10 Half of the HS students in this program stated that the program increased their consideration of a career in medicine.10 Several students reported that the program led them to pursue related opportunities at the HS and undergraduate levels.10 All undergraduates surveyed at the time of the study agreed that the program improved their understanding of neuroscience and clinical neurology and that teaching HS students improved this understanding. These students reported that the pipeline affected their career or subspecialty plans and enabled them to form beneficial mentoring relationships.10 Long-term results of the program have not yet been published although are promising (written communication with the study authors). Introducing neuroscience and neurology to students at a young age can increase interest early on and encourage the participation in other neuroscience opportunities at later stages.
Most participants from our study were White (63%) or Asian (25%), which matches the demographic representation of graduating medical students pursuing a career in neurology (61% and 19%, respectively).4 To increase diverse representation within the field, early exposure is especially important. A recent virtual program conducted at the Massachusetts General Hospital during COVID-19 collaborated with organizations that support underrepresented students to recruit and offer 31 HS and undergraduate students a paid opportunity to participate in neurology research and interact with neurologists. There was a dramatic increase in interest in pursuing a career in neurology (21%–90%) from the beginning to the end of the program. Early engagement helps educate and encourage students from underrepresented backgrounds to consider neurology as a feasible career choice.11
Inclusion of Clinical Neurology Information in Undergraduate and HS Curricula
Including clinical neurology information into HS biology courses and undergraduate neuroscience courses may also help strengthen the pipeline. Incorporating relevant articles, guest speakers, and clinical correlations may be effective in providing career insight and creating networking opportunities for undergraduates. The inclusion of clinical information in basic coursework was cited by medical trainees to contribute to specialty interest.5
Increasing Undergraduate Exposure to Neurologists and Clinical Neurology
Although less than one-third of the students had spoken with a neurologist about career experience, of those who had, almost all found it beneficial. Personal connections were the most common resource cited by undergraduates for getting connected directly with a neurologist. Such privileged connections can contribute to the lack of diversity in the pipeline. Creating systematic ways to facilitate interaction with neurologists through both communication opportunities and mentoring relationships is key, especially for those who identify as underrepresented minorities (URMs) to strengthen the neurology pipeline and increase diversity.12 Undergraduate students found that working with neurologist clinician-researchers helped them identify necessary skills for the career path, gain insight from their mentors, and assess their career goals, citing the experience offered valuable perspective and increased their interest in medicine, neuroscience, and neurology.12 Mentorship by neurologists during the undergraduate years can excite students about the field and accurately depict the career of a neurologist.12 Thus, one way to increase exposure to neurologists and clinical neurology at the undergraduate level is to create programs that pair neurologists and undergraduates, which would allow for discussions surrounding career choice, improved communication skills, improved teamwork skills, and understanding of scientific and clinical methodologies.12 Such programs could entail the following: (1) engaging interested physicians; (2) characterizing potential opportunities available; and (3) ensuring access and exposure of opportunities to undergraduate students. Furthermore, such programs often positively affect the mentoring neurologist, providing a sense of purpose and potentially alleviating burnout.12,21
With the Covid-19 pandemic and transition to virtual learning, there has been a growth in telementoring opportunities in neurology. For example, the Duke Department of Neurology allows undergraduates or recent graduates to shadow a neurologist.13 The Lenox Hill Department of Neurosurgery also offers virtual exposure to clinical neurology through the BRAINterns program in which HS, undergraduate, and medical students can shadow neurosurgeons, learn through webinars, and complete projects related to medical school applications.14 Such exposure and support is valued and relevant to the goals of the pipeline.14 Virtual opportunities may especially help students who listed barriers related to location (Table 5) and whose university is not large/affiliated with a medical center. Given the recent emergence of such programs, more outcomes research is needed to assess value and need.
Although interest was high in wanting clinical neurology experiences, only 43% of participants had attempted to gain such experiences (Table 4). The top reason for not attempting was COVID-19 prevalence (eTable 2, links.lww.com/WNL/B735), leaving uncertainty as to what typically occurs during nonpandemic times. Analyses comparing those who had spoken to a neurologist about career experiences with those who had not and those who had attempted to gain clinical neurology experiences with those who had not and found that those with exposure/experiences were younger when first exposed to neuroscience, more likely to cite physician as a career goal, and more likely to be upperclassmen. Race, ethnicity, and sex did not seem to differentiate such students. This further demonstrates the importance of early exposure and targeting students interested in a career in medicine. Those majoring in neuroscience were more likely to have gained clinical neurology experiences and more likely to have experience conducting neuroscience research. Given the cross-sectional nature of the survey, it is difficult to determine whether those with a major had more access to more opportunities or were more likely to seek out such opportunities given their defined interests.
Organizational Support of Undergraduate Interest
Several organizations could play a critical role in bridging the gap between undergraduate interest in neurosciences and clinical neurology careers. The AAN is clearly a promising contributor to initiatives to increase early interest in neurology. Formal programming such as mentorship opportunities and visits to educational institutions could promote connections between undergraduates and AAN members. For example, the AAN has an Internship Program that provides support for undergraduates to work with AAN neurologists12,21 and a Pipeline Subcommittee dedicated to finding innovative ways to increase the number of students entering neurology.21,22 The National Institute of Neurological Disorders and Stroke (NINDS) currently supports some summer research projects but largely focuses on relevant basic science curriculum. Although funding is available to support educational endeavors, such as Research Education Programs (R25, with 9 programs currently funded),15 the NINDS could issue a call for more proposals for clinical neurology research projects that can allow for clinical research mentorship opportunities between neurologists and students. Diversity supplements from the NIH can fund students as early as HS to engage with currently funded NIH researchers.16
Opportunities for Assessments to Improve Intervention Development and Implementation
To understand the impact, pre-post assessments, longitudinal analyses, and comparisons of programs will be important to determine best methods for implementation. For example, are one-on-one meetings more effective than group programs? Are one-time shadowing experiences sufficient, or are longitudinal experiences necessary?
Strengths, Weaknesses, and Future Directions
The survey included a broad representation of students from across the United States from at least 40 varied institutions, although there may be response bias where those who feel most strongly about the topic complete the survey.17 Survey distribution during the pre-vaccine COVID pandemic may have affected results; participants described the pandemic's impact as a barrier to neuroscience/neurology exposure. Additional research will need to be conducted during nonpandemic times to follow-up on these results. The low response rate increases the likelihood of selection bias. The anonymous results prevent the ability to verify responses to objective data (such as grade point averages and correlate results to access to resources.
Future research might (1) include a more detailed qualitative analysis at specific institutions and (2) examine existing opportunities and the importance of how the early exposure that many respondents cited influence later career decisions, which is especially important to understand for those from underrepresented backgrounds. Of interest, students reported that they were most interested in dementia, traumatic brain injury, and neuro-oncology. This deserves further exploration to determine whether it is because of personal experience, the media, or school exposure (within the classroom or in extracurricular activities). Future research may examine how students become aware of topics and ways to expose students to a variety of neurologic conditions. In particular, it may be beneficial to expose students to neurologic conditions for which there is a shortage of subspecialists. We do not know the percent of students who gained neurology exposure that led to a decision against further neurosciences.
Furthermore, given the lack of participant diversity, future work must target and represent the experiences and perspectives of students interested in the neurosciences from URMs. The lack of diversity may be stemming from underrepresentation in Science, Technology, Engineering, and Mathematics (STEM), which is why the NIH (SEPA grant),18 NY State (STEP programs),19 and other groups are now offering pipeline programs to foster interest in STEM in URM. Moreover, research has demonstrated that when students from underrepresented backgrounds are able to engage in neurology education and research, as early as HS, they are more likely to indicate interest in pursuing a career in neurology when surveyed.11 Finally, research can be conducted to determine whether there are methods and support systems that can maintain students' interest in neuroscience/neurology as they enter medical school to prevent neurophobia.20
Study Funding
NCCIH K23K23AT009706 (PI-M. Minen) NCCIH K23AT008406 (PI- R.E. Wells) Funding is the salary support from the 2 K23 awards (R.E. Wells and M.T. Minen). The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.
Disclosure
The authors report no disclosures relevant to the manuscript. Go to Neurology.org/N for full disclosures.
Acknowledgment
The authors thank Ms. Mariana Espinosa-Polanco and Ms. Jenny Guiracocha and undergraduate students who helped to develop and edit the survey. They also thank all of the undergraduate neuroscience faculty for brainstorming about the survey and/or reviewing the survey and providing feedback: Judith Mosinger Ogilvie, Ph.D. (St. Louis University), Samantha S Gizerian, PhD (Washington State University), Patrick Sonner, PhD (Wright State University), and Mark Pendergast, PhD (University of Kentucky). The authors thank the American Academy of Neurology Insights Team for their review of the survey, feedback, and help with the qualitative analyses. They also thank Dr. Raddy Ramos for inspiring them to study the connection between the undergraduate neurosciences and clinical neurology and for introducing them to the Faculty for Undergraduate Neuroscience (FUN) Society. They also thank all the neuroscience faculty who distributed the survey, especially Peter Balsam, PhD (Barnard College, Columbia University), who got IRB approval from his institution per his institution's requirements, and all the students who completed the survey. R.E. Wells and M.T. Minen also appreciate having had the opportunity to serve as mentors through the AAN Neuroscience, a rewarding Internship opportunity for undergraduate students.
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.
- Received July 2, 2021.
- Accepted in final form December 17, 2021.
- © 2021 American Academy of Neurology
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