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Neurology residency directors reflect back on the way training has shifted in the last 20 yearsfrom training and work limits for residents to new models for assessing skills.

With the understanding of a host of neurologic diseases growing at an impressive pace, neurology residency programs have plenty of new discoveries and topics to consider.

Just 20 years ago, stroke care was in its infancy and neurologists were only starting to experience the potential of tissue plasminogen activator (tPA) to limit the devastating effects of acute stroke. Now with the introduction of mechanical thrombectomy, stroke care has evolved even more, as have therapies for everything from multiple sclerosis (MS) to epilepsy.

It used to be that residency programs could teach residents the field of neurologythis is what's out there and this is what you should know is comingbut now that's impossible, said Shannon M. Kilgore, MD, FAAN, who serves as the site director of the Stanford University neurology residency program. The depth and breadth of neurology is so big at this point that there is no way to cover everything.

Exposing residents to a spectrum of neurologic diseases and degrees of illness remains at the heart of clinical rotations in neurology training, Dr. Kilgore said, but there also is a shift toward the goal of creating learners, life-long learners. It's about teaching trainees how to access information, how to recognize when they don't know something and seek out information from someone else or another resource.

Other key changes in neurology training in recent years include limitations on how many hours residents can work each week (80 is the magic number); the use of milestones to track residents' advancement through levels of mastering skill sets (such as diagnosis and management of neurologic emergencies); and more attention to broader societal issues such as diversity, inclusion, cultural awareness, inherent bias, and health care access and inequities.

A lot has changed and a lot has not changed, said Ralph Jzefowicz, MD, FAAN, who at the end of this year will step down after 25 years as program director of the neurology residency program at the University of Rochester School of Medicine and Dentistry.

On the change side, Dr. Jzefowicz said neurology is shedding its image of being a kind of laid-back specialty where there isn't much for practitioners to do besides making diagnoses and managing symptoms as best they can. When he began training residents, stroke was not considered a medical emergency, and largely involved admitting a patient to the hospital, providing physical and occupational therapy, and transferring the patient to a rehabilitation facility or a nursing home depending upon the severity of the neurologic deficit.

Dr. Jzefowicz, professor of neurology and medicine, said, What hasn't changed is the aim to turn out residents who are physicians foremost with the knowledge to care for patients with neurologic disorders, outstanding teachers, as well as leaders who are kind, compassionate, and have humanistic skills.

Pierre Fayad, MD, FAAN, FAHA, who served as neurology residency program director for more than 12 years at the University of Nebraska Medical Center and is currently a member of the neurology residency review committee for the American Council for Graduate Medical Education (ACGME), said, The key shift in neurology training, as in other specialties, has been to move away from a very structured, prescriptive approachthe prescriptive do these rotations, cover these core subjects toward assessing a training experience focused on clinical competencies and milestone achievement.

There are various milestones for what we feel are important things for a neurology resident to achieve in training, said Dr. Fayad, professor of neurological sciences and chief of vascular neurology and the stroke division of the University of Nebraska Medical Center. Assessing residents using 27 milestones, which began in 2013 and was updated this year, gives us a much bigger and better picture of the progress of residents, he said.

The 27 milestones, grouped under six major domains of physician competency, are each rated from 1 (novice) to 5 (expert). For instance, in a milestone for Interpretation of Neuroimaging, residents advance from Level 1 (identifies basic neuroanatomy on brain and vascular anatomy of the head and MRI and CT) to Level 5 (interprets advanced neuroimaging).

The specialty of neurology has grown tremendously because of the massive expansion in knowledge and therapeutics that led to subspecialization within neurology to carry forward the science and clinical practice, said Dr. Fayad, who noted there are now 10 ACGME-approved neurology subspecialties and many others that are not yet approved by the ACGME.

A big challenge for the neurology residency is parceling out the knowledge from each of the subspecialties and integrating them to a general neurologist's need, he said. An example is incorporating some of the critical content and practice from endovascular surgical neuroradiology into the neurology residency. Other subspecialties with such challenges include MS and neuro-oncology, which require a significant knowledge and comfort with managing immune therapies, or movement disorders and epilepsy, which are heavy in surgical therapies, procedures, and pharmacotherapies.

He said telehealth, which became quite common in neurology during the early months of the pandemic, will eventually need to be officially incorporated into neurology residency training.

Dr. Fayad said residency directors have a lot of balls to juggle: They need to consider the professional interests and goals of individual residents, the on-call demands of a given servicevascular and endovascular neurology require availability 24 hours a day on an urgent basiswhile other specialties do not have such needs, the impact of urgent calls on residents' well-being, and compliance to the 80-hour work requirement.

Carlo S. Tornatore, MD, professor and chair of neurology at Georgetown University Medical Center, was residency director from 1998 to 2015. He believes the decision to limit residents' hours has led to mostly positive results, though he said there needs to be extra attention on good communication when handing a patient off from one doctor to the next. The adoption of electronic medical records helps.

There is no question that work hours are more humane and respectful of our learners, and the whole purpose of residency is to learn, he said.

Dr. Tornatore said that with advances in stroke care, spending time on stroke service is all the more critical for residents, but he said inpatient, acute-care experience shouldn't be emphasized at the expense of outpatient services because that is where most neurologic care is delivered.

Our goal is to train somebody who is highly competent as a general neurologist and who can easily pass the boards, he said, though most residents do go on to specialty training.

I think a general trend (in training) has been to have residents spend more time in the outpatient setting, he said, which helps connect residents with the everyday practice of neurology and the dynamics outside the walls of the hospital.

Dr. Tornatore, who specializes in MS, said the COVID-19 pandemic brought front and center to his residents the pressing issue of health disparities and inequities in health care access in low income and minority communities.

What we learned during the pandemic is that lack of access to care and the incredible inequities in care absolutely had an impact on patients' risk of developing COVID-19 or being hospitalized and dying from COVID, he said. He said part of medical education and training has to focus on what doctors can do within their institutions and communities to address health inequities and disparities, including being cognizant of the inherent biases they may bring into patient encounters.

It's getting at the idea that when you see a person don't immediately jump to the conclusion, I know this person and what they are about, he said.

He said Georgetown University Medical Center has undertaken multiple initiatives to address issues of diversity, inclusion, and equity, including the establishment of the Racial Justice Committee for Change, which consists of attending staff, fellows, residents, medical students, patients, and staff. Dr. Tornatore said the committee has been tasked to make tangible and meaningful changes over the next year to address diversity, inclusion, and equity concerns.

Wendy Peltier, MD, associate professor of neurology and medicine at the Medical College of Wisconsin, said she wonders whether the holistic side of being a doctor is being shortchanged amid the need to teach all sorts of new developments in neurology while still keeping training hours in check.

I think it is important for medicine as a whole to have a broader approach for doctors in training, to focus on not just what they learn but how they grow as humans, she said.

Dr. Peltier, who was neurology residency director for a decade and now specializes in palliative care, said she's not advocating a return to the days when she once worked 100 days in a row as an intern during the HIV/AIDS epidemic, but said today's trainees may be perhaps missing a little of that lived and shared experience with a patient.

I can look back and say my (training) experiences brought me so close to patients and families and made me the doctor I am today, she said. The joy I got from the patientdoctor relationship empowered me to stay active in neurology.

Dr. Peltier said that one trend in neurologic care that she finds particularly exciting is the growth in using multidisciplinary care teams in field such as amyotrophic lateral sclerosis, MS and memory care, so there needs to be an emphasis on residents learning how to be a leader of a team.

Stanford's Dr. Kilgore, who has served on the ACGME's Review Committee for Neurology, said neurology training of the future needs to be organized in such a way to help address the unmet need for neurologists in many communities, including rural America, which contributes to inequities in care.

Training is inherently tied to hospital care [due to Medicare funding of GME], but we have historically woefully undertrained in the outpatient clinics, she said. Residents are really uncomfortable going into practice where they are going to see patients mostly in a clinic because that's not what they've been doing for four years.

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20 Years Later, Neurology Training Transitions with New... : Neurology Today - LWW Journals