Changes to Child Neurology Training Possible

Over the next several months, the Accreditation Council for Graduate Medical Education is scheduled to consider a proposal that would decrease the amount of time that child neurology residents spend on inpatient adult neurology training.

The proposal is currently being considered by the ACGME’s Neurology Residency Review Committee and could move to the Committee on Requirements next year.

Currently, residents spend 12 months in adult neurology training, with as much as 9 months working in an inpatient setting in some cases. The proposal would limit adult inpatient work to 6 months, and mandate that residents spend a certain amount of their adult training time working in outpatient clinics. The proposal would also offer more elective options for residents during the adult neurology year, giving them the chance to train in virtually any part of the specialty from neuroradiology to neuropathology.

If the ACGME approves the proposal in early 2013, the soonest it could go into effect would be July 2013, said Dr. Phillip L. Pearl, chief of neurology at Children’s National Medical Center in Washington and a member of the Neurology Residency Review Committee.

The proposal emerged in large part because of concerns that child neurology residents were spending too much of the adult training year functioning as interns on adult stroke services, Dr. Pearl said.

"I think we’ve come to agreement that we see the value of maintaining strong adult neurology training, but opening it up and diversifying it," said Dr. Pearl, who is also the president of the Professors of Child Neurology.

Keeping the year of adult neurology training intact is important, Dr. Pearl said, because it provides a foundation to create "child neurologists and not neurological pediatricians."

"Neurologists think differently than pediatricians," he said. "The child neurologist does need to be able to take care of strokes, and movement disorders, and multiple sclerosis in children, and be able to localize neurological deficits in children. The best way to learn that process is in adults, where the disorders and localizable deficits are much more common."

Maintaining the connection to adult neurology training is also critical because it allows child neurologists to remain boarded in both adult and child neurology, Dr. Pearl said.

But continuing with the full 12 months of training in adult neurology is controversial, even with the increased emphasis on outpatient work.

Courtesy Cincinnati Children's Hospital Medical Center

Dr. Donald L. Gilbert, the child neurology residency program director at Cincinnati Children’s Hospital Medical Center in Ohio, said the proposal under review by the Residency Review Committee is "inadequate." Instead, he wants to see the requirement for adult training reduced to 3 months, followed by an additional 3 months of electives.

"Flexibility is the way to go," he said.

The reasons for ratcheting down the adult requirement are practical, Dr. Gilbert said. Today’s child neurologist doesn’t see that many adult patients. Dr. Gilbert and his colleagues recently conducted a survey of 437 child neurologists who were certified between 2001 and 2010. Of the 179 who responded, only about 3% reported that they provided general adult neurology services in their practices. About two-thirds of those who responded said they provided no adult neurology services.

"We need to train people to take care of whom they are going to take care of," he said.

The other problem with requiring a full year of adult neurology training is that it takes time away from the child neurology side of training, Dr. Gilbert said.

"You miss getting to see those kids if you’re spending that time in the adult inpatient service managing strokes and high blood pressure, diabetes, and chronic lung disease from smoking," he said.

Dr. Keith R. Ridel, a child neurologist in private practice in Indianapolis, agrees that the requirement for 12 months of adult neurology is outdated.

"Everybody will agree that the adult training is helpful, but how much of that you apply to your practice is debatable," he said.

Dr. Ridel, who works in a large neurology practice, said about a quarter of his patients are adults aged 18-30 years. He estimates that even with such a large number of adult patients, he applies only about half of what he learned during his adult training year to his day-to-day practice.

But other leaders in the field said the adult training year has significant value in creating a foundation of analytical skills for the new neurologist.

Dr. Donna M. Ferriero, who is a neonatal neurologist, said what she learned in her adult neurology training helps her to elicit signs and symptoms in the newborn.

Dr. Ferriero, who chairs the department of pediatrics at the University of California, San Francisco, Benioff Children’s Hospital, said residents today probably don’t need a full year of adult neurology, but they do need to spend a substantial portion of that first year learning about adult neurologic diagnosis and treatment. That type of training could also be incorporated into elective rotations, provided the training spans the developmental spectrum from cradle to grave, she said.

"Fundamentally we’re neurologists and we need neurologic training," she said.

The adult neurology training year also helps residents to build their basic diagnostic skills on patients who are often less complex and more compliant before moving on to children, said Dr. Nina F. Schor, professor and chair of the department of pediatrics at the University of Rochester (N.Y.).

For example, a resident who tried to conduct her first mental status exam on a 3-month-old would likely have a much harder time than if she mastered her skills first on adults and then adapted the exam to make it developmentally and age appropriate, Dr. Schor said.

Dr. Scott Pomeroy, the chair of neurology at Boston Children’s Hospital, said the number of months of adult training is less important than the content. At Boston Children’s Hospital, they already limit residents’ adult inpatient time to 6 months. During the other 6 months, residents participate in an outpatient adult neurology rotation. That rotation gives the residents a fuller picture of adult neurology and knowledge that is applicable to pediatric patients, he said.

"The distinction between adult and pediatric neurology for some diseases is not as striking as it used to be," Dr. Pomeroy said. "We used to think of multiple sclerosis as an adult disease. We now know that’s not true. There’s lots of kids that have it."

Leaders in adult and child neurology need to work together to improve the curriculum, he said. Both adult and child neurology residents would benefit from greater knowledge about neurogenetics, for example.

"If cool minds sat down and hammered out some agreement, we could get out of this ‘how many months of adult neurology’ discussion and into the discussion of how can we jointly improve our training experience," Dr. Pomeroy said. "This other thing is a big distraction."

Over the next several months, the Accreditation Council for Graduate Medical Education is scheduled to consider a proposal that would decrease the amount of time that child neurology residents spend on inpatient adult neurology training.

The proposal is currently being considered by the ACGME’s Neurology Residency Review Committee and could move to the Committee on Requirements next year.

Currently, residents spend 12 months in adult neurology training, with as much as 9 months working in an inpatient setting in some cases. The proposal would limit adult inpatient work to 6 months, and mandate that residents spend a certain amount of their adult training time working in outpatient clinics. The proposal would also offer more elective options for residents during the adult neurology year, giving them the chance to train in virtually any part of the specialty from neuroradiology to neuropathology.

If the ACGME approves the proposal in early 2013, the soonest it could go into effect would be July 2013, said Dr. Phillip L. Pearl, chief of neurology at Children’s National Medical Center in Washington and a member of the Neurology Residency Review Committee.

The proposal emerged in large part because of concerns that child neurology residents were spending too much of the adult training year functioning as interns on adult stroke services, Dr. Pearl said.

"I think we’ve come to agreement that we see the value of maintaining strong adult neurology training, but opening it up and diversifying it," said Dr. Pearl, who is also the president of the Professors of Child Neurology.

Keeping the year of adult neurology training intact is important, Dr. Pearl said, because it provides a foundation to create "child neurologists and not neurological pediatricians."

"Neurologists think differently than pediatricians," he said. "The child neurologist does need to be able to take care of strokes, and movement disorders, and multiple sclerosis in children, and be able to localize neurological deficits in children. The best way to learn that process is in adults, where the disorders and localizable deficits are much more common."

Maintaining the connection to adult neurology training is also critical because it allows child neurologists to remain boarded in both adult and child neurology, Dr. Pearl said.

But continuing with the full 12 months of training in adult neurology is controversial, even with the increased emphasis on outpatient work.

Courtesy Cincinnati Children's Hospital Medical Center

Dr. Donald L. Gilbert, the child neurology residency program director at Cincinnati Children’s Hospital Medical Center in Ohio, said the proposal under review by the Residency Review Committee is "inadequate." Instead, he wants to see the requirement for adult training reduced to 3 months, followed by an additional 3 months of electives.

"Flexibility is the way to go," he said.

The reasons for ratcheting down the adult requirement are practical, Dr. Gilbert said. Today’s child neurologist doesn’t see that many adult patients. Dr. Gilbert and his colleagues recently conducted a survey of 437 child neurologists who were certified between 2001 and 2010. Of the 179 who responded, only about 3% reported that they provided general adult neurology services in their practices. About two-thirds of those who responded said they provided no adult neurology services.

"We need to train people to take care of whom they are going to take care of," he said.

The other problem with requiring a full year of adult neurology training is that it takes time away from the child neurology side of training, Dr. Gilbert said.

"You miss getting to see those kids if you’re spending that time in the adult inpatient service managing strokes and high blood pressure, diabetes, and chronic lung disease from smoking," he said.

Dr. Keith R. Ridel, a child neurologist in private practice in Indianapolis, agrees that the requirement for 12 months of adult neurology is outdated.

"Everybody will agree that the adult training is helpful, but how much of that you apply to your practice is debatable," he said.

Dr. Ridel, who works in a large neurology practice, said about a quarter of his patients are adults aged 18-30 years. He estimates that even with such a large number of adult patients, he applies only about half of what he learned during his adult training year to his day-to-day practice.

But other leaders in the field said the adult training year has significant value in creating a foundation of analytical skills for the new neurologist.

Dr. Donna M. Ferriero, who is a neonatal neurologist, said what she learned in her adult neurology training helps her to elicit signs and symptoms in the newborn.

Dr. Ferriero, who chairs the department of pediatrics at the University of California, San Francisco, Benioff Children’s Hospital, said residents today probably don’t need a full year of adult neurology, but they do need to spend a substantial portion of that first year learning about adult neurologic diagnosis and treatment. That type of training could also be incorporated into elective rotations, provided the training spans the developmental spectrum from cradle to grave, she said.

"Fundamentally we’re neurologists and we need neurologic training," she said.

The adult neurology training year also helps residents to build their basic diagnostic skills on patients who are often less complex and more compliant before moving on to children, said Dr. Nina F. Schor, professor and chair of the department of pediatrics at the University of Rochester (N.Y.).

For example, a resident who tried to conduct her first mental status exam on a 3-month-old would likely have a much harder time than if she mastered her skills first on adults and then adapted the exam to make it developmentally and age appropriate, Dr. Schor said.

Dr. Scott Pomeroy, the chair of neurology at Boston Children’s Hospital, said the number of months of adult training is less important than the content. At Boston Children’s Hospital, they already limit residents’ adult inpatient time to 6 months. During the other 6 months, residents participate in an outpatient adult neurology rotation. That rotation gives the residents a fuller picture of adult neurology and knowledge that is applicable to pediatric patients, he said.

"The distinction between adult and pediatric neurology for some diseases is not as striking as it used to be," Dr. Pomeroy said. "We used to think of multiple sclerosis as an adult disease. We now know that’s not true. There’s lots of kids that have it."

Leaders in adult and child neurology need to work together to improve the curriculum, he said. Both adult and child neurology residents would benefit from greater knowledge about neurogenetics, for example.

"If cool minds sat down and hammered out some agreement, we could get out of this ‘how many months of adult neurology’ discussion and into the discussion of how can we jointly improve our training experience," Dr. Pomeroy said. "This other thing is a big distraction."

Over the next several months, the Accreditation Council for Graduate Medical Education is scheduled to consider a proposal that would decrease the amount of time that child neurology residents spend on inpatient adult neurology training.

The proposal is currently being considered by the ACGME’s Neurology Residency Review Committee and could move to the Committee on Requirements next year.

Currently, residents spend 12 months in adult neurology training, with as much as 9 months working in an inpatient setting in some cases. The proposal would limit adult inpatient work to 6 months, and mandate that residents spend a certain amount of their adult training time working in outpatient clinics. The proposal would also offer more elective options for residents during the adult neurology year, giving them the chance to train in virtually any part of the specialty from neuroradiology to neuropathology.

If the ACGME approves the proposal in early 2013, the soonest it could go into effect would be July 2013, said Dr. Phillip L. Pearl, chief of neurology at Children’s National Medical Center in Washington and a member of the Neurology Residency Review Committee.

The proposal emerged in large part because of concerns that child neurology residents were spending too much of the adult training year functioning as interns on adult stroke services, Dr. Pearl said.

"I think we’ve come to agreement that we see the value of maintaining strong adult neurology training, but opening it up and diversifying it," said Dr. Pearl, who is also the president of the Professors of Child Neurology.

Keeping the year of adult neurology training intact is important, Dr. Pearl said, because it provides a foundation to create "child neurologists and not neurological pediatricians."

"Neurologists think differently than pediatricians," he said. "The child neurologist does need to be able to take care of strokes, and movement disorders, and multiple sclerosis in children, and be able to localize neurological deficits in children. The best way to learn that process is in adults, where the disorders and localizable deficits are much more common."

Maintaining the connection to adult neurology training is also critical because it allows child neurologists to remain boarded in both adult and child neurology, Dr. Pearl said.

But continuing with the full 12 months of training in adult neurology is controversial, even with the increased emphasis on outpatient work.

Courtesy Cincinnati Children's Hospital Medical Center

Dr. Donald L. Gilbert, the child neurology residency program director at Cincinnati Children’s Hospital Medical Center in Ohio, said the proposal under review by the Residency Review Committee is "inadequate." Instead, he wants to see the requirement for adult training reduced to 3 months, followed by an additional 3 months of electives.

"Flexibility is the way to go," he said.

The reasons for ratcheting down the adult requirement are practical, Dr. Gilbert said. Today’s child neurologist doesn’t see that many adult patients. Dr. Gilbert and his colleagues recently conducted a survey of 437 child neurologists who were certified between 2001 and 2010. Of the 179 who responded, only about 3% reported that they provided general adult neurology services in their practices. About two-thirds of those who responded said they provided no adult neurology services.

"We need to train people to take care of whom they are going to take care of," he said.

The other problem with requiring a full year of adult neurology training is that it takes time away from the child neurology side of training, Dr. Gilbert said.

"You miss getting to see those kids if you’re spending that time in the adult inpatient service managing strokes and high blood pressure, diabetes, and chronic lung disease from smoking," he said.

Dr. Keith R. Ridel, a child neurologist in private practice in Indianapolis, agrees that the requirement for 12 months of adult neurology is outdated.

"Everybody will agree that the adult training is helpful, but how much of that you apply to your practice is debatable," he said.

Dr. Ridel, who works in a large neurology practice, said about a quarter of his patients are adults aged 18-30 years. He estimates that even with such a large number of adult patients, he applies only about half of what he learned during his adult training year to his day-to-day practice.

But other leaders in the field said the adult training year has significant value in creating a foundation of analytical skills for the new neurologist.

Dr. Donna M. Ferriero, who is a neonatal neurologist, said what she learned in her adult neurology training helps her to elicit signs and symptoms in the newborn.

Dr. Ferriero, who chairs the department of pediatrics at the University of California, San Francisco, Benioff Children’s Hospital, said residents today probably don’t need a full year of adult neurology, but they do need to spend a substantial portion of that first year learning about adult neurologic diagnosis and treatment. That type of training could also be incorporated into elective rotations, provided the training spans the developmental spectrum from cradle to grave, she said.

"Fundamentally we’re neurologists and we need neurologic training," she said.

The adult neurology training year also helps residents to build their basic diagnostic skills on patients who are often less complex and more compliant before moving on to children, said Dr. Nina F. Schor, professor and chair of the department of pediatrics at the University of Rochester (N.Y.).

For example, a resident who tried to conduct her first mental status exam on a 3-month-old would likely have a much harder time than if she mastered her skills first on adults and then adapted the exam to make it developmentally and age appropriate, Dr. Schor said.

Dr. Scott Pomeroy, the chair of neurology at Boston Children’s Hospital, said the number of months of adult training is less important than the content. At Boston Children’s Hospital, they already limit residents’ adult inpatient time to 6 months. During the other 6 months, residents participate in an outpatient adult neurology rotation. That rotation gives the residents a fuller picture of adult neurology and knowledge that is applicable to pediatric patients, he said.

"The distinction between adult and pediatric neurology for some diseases is not as striking as it used to be," Dr. Pomeroy said. "We used to think of multiple sclerosis as an adult disease. We now know that’s not true. There’s lots of kids that have it."

Leaders in adult and child neurology need to work together to improve the curriculum, he said. Both adult and child neurology residents would benefit from greater knowledge about neurogenetics, for example.

"If cool minds sat down and hammered out some agreement, we could get out of this ‘how many months of adult neurology’ discussion and into the discussion of how can we jointly improve our training experience," Dr. Pomeroy said. "This other thing is a big distraction."