Neurology -- Correspondence for Adair et al., 67 (6) 936-939

Correspondence published:

Survey of training programs’ means for promoting neurology and attracting trainees: William G. Preston, MD, FAAN (9 November 2006)

Reply from the Authors: John C. Adair, John R. Corboy (9 November 2006)

Survey of training programs’ means for promoting neurology and attracting trainees 9 November 2006

William G. Preston, MD, FAAN,
Associate Clinical Professor of Neurology, UCI School of Medicine
Neuroscience Medical Group, 23961 Calle Magdalena, #317 Laguna Hills CA 92653
Send Correspondence to journal:
Re: Survey of training programs’ means for promoting neurology and attracting trainees

wpreston{at}aol.com William G. Preston, MD, FAAN

In their recent article, Adair et al note some of the defining factors influencing program choice in neurology training opportunities. [1] Their not-too-subtle conclusion is that many neurology training programs, and by extension the entire specialty of neurology, may be in for a rough ride: "available (residency) positions continue to exceed the number of American medical school graduates interested in neurology."
Throughout the article's ensuing "wherefores and whys," the proffered explanations seem to circumvent, and leave largely unexplored, one of the most obvious means to increase interest in neurology training programs and the entire field of neurological science in general: neurologists' active involvement with neuroimaging.
As many neurologists now find themselves with fewer economic opportunities relative to other, perhaps more procedurally oriented, medical subspecialties (as with cardiology), it seems that neuroimaging is the veritable "elephant in the room."
After years of ambivalence with regard to neuroimaging, the neurological community has recently begun to review practice domain imperatives and priorities. Neurologist involvement with neuroimaging has been an active topic within the American Society of Neuroimaging for many years, and it is now seriously considered by many in the American Academy of Neurology, both rank and file and academic members.
With the recent addition of Neuroimaging into the United Council of Neurologic Subspecialties (UCNS), the entire concept of neurologist neuroimaging now deserves re-examination, updating and, hopefully, emphasis at the AAN Board of Directors level.
Some practicing neurologists remember Bill Oldendorf's cautionary advice to neurologists some 20 years ago, urging neurologists' active involvement ("on the ground floor") with the "new magnetic imaging technology that has absolutely nothing to do with Roentgen."
Somewhere along the path, neurologists dropped the neuroimaging ball (or was the ball volitionally "thrown down" as some would suggest?), so that many neurologists have unwittingly deferred the right and privilege of interpreting (usually their own referrals) neuroimaging studies to other specialties with less clinical knowledge, and often with less interpreting expertise.
Neurological advocacy, at both the resident training and practitioner levels, and promotion of clinical "practice domain" policy start at the top: until neuroimaging is officially sanctioned by the AAN as a rightful extension of the neurologist's purview, with appropriate educational ramifications at the residency training and CME levels, little will change, and a golden opportunity for the specialty will be lost.
References
1. Adair JC, Rudnicki SA, Boudreau E, Weiner WJ, Coyle PK, Corboy JR. Survey of training programs’ means for promoting neurology and attracting trainees Neurology 2006; 67: 936-939.
Disclosure: The author reports no conflicts of interest.

Reply from the Authors 9 November 2006

John C. Adair,
Department of Neurology, University of New Mexico
Neurology Svc. (127), Albuquerque VA, 1501 San Pedro SE, Albuquerque, NM 87108,
John R. Corboy
Send Correspondence to journal:
Re: Reply from the Authors

john.adair{at}med.va.gov John C. Adair, et al.

The Graduate Education Subcommittee (GES) of the AAN Education Committee appreciates Dr. Preston’s insights about our survey. His remarks raise an important subject not addressed directly in our report.
To begin framing the issue of how to match “the best and brightest”, the GES sought to determine how departments introduce our specialty to medical students. Program features that influence current residents’ (i.e., former students’) judgments about training site selection provided complementary information about match success. A more fundamental question about what motivates choosing a career in clinical neuroscience, broached by Dr. Preston and reviewers, awaits more ambitious investigation.
Dr. Preston suggests reasonably that “active involvement” in neuroimaging might provide a means of generating interest in neurology. The recommendation appeals to common sense on several levels. Fascination with neuroanatomy and its application to clinical problems often impels students to cultivating further interest in the organ system. Imaging technology now resolves structures in detail rivaling or superior to inspection of gross specimens in the anatomy lab. The intellectual satisfaction of solving clinical conundrums, through integrating clinical observation with anatomic and physiological studies, provides a major impetus for pursuing the clinical neurosciences. However, Dr. Preston’s letter identifies a more pragmatic motivation: neuroimaging offers the potential of enhancing revenue for the practicing neurologist, not to mention the academic department. Medical curricula pay little formal heed to economic aspects of return for services rendered and the fiscal realities of practice survival.
Undoubtedly, many students develop some hunch about income differential between specialties, and it would be surprising if future surveys fail to find that such considerations play at least some role in deciding about a career in neurology.
The most appealing of Dr. Preston’s comments concerns whether our specialty can “do well by doing good”. In contrast to many specialties, most neurologists view imaging studies they order, evaluating both technical quality and judging the relevance of findings. As mentioned, the neurologist may have more experience interpreting neuroimaging than the radiologist. And while both share the responsibility for a study’s disposition, only the radiologist receives financial return.
Efforts on behalf of neurology by the ASNR and UCNS have resulted in means through which trainees may acquire certification for proficiency in neuroimaging. However, substantial additional efforts will be required for regulatory approval of neurologists treading on radiologists’ turf. Such advocacy would be facilitated if neurology can demonstrate comparable or superior outcomes for our “active involvement”.
Disclosure: The authors report no conflicts of interest.