Training for the Future, Not the Past

Ignorance more frequently begets confidence than does knowledge.
                                                                        –– Charles Darwin

The practice of child neurology has changed dramatically in recent years, but the rules governing our training programs and the curriculums they offer have remained relatively static. There has been considerable debate about what constitutes optimal training for child neurologists and how to institute meaningful changes, given the limits imposed by the Residency Review Committee and the American Board of Psychiatry and Neurology. This year will also mark the first child neurology residency match under the auspices of the National Resident Matching Program.

A Rite of Passage

Currently 12 of the 36 months of child neurology training are allocated to adult neurology rotations. When this approach was adopted, caring for adults with focal neurological lesions was arguably the best way to master neurological anatomy and lesion localization, and many child neurologists in those days cared for adults as well as children. Studying adult neurology may still have value, but is it more valuable than rotations such as genetics, neuro-imaging, and pediatric critical care? In a few programs, the adult neurology months are heavily weighted toward inpatient care with little exposure to outpatients or to diagnostic studies. Even those who argue for continuation of the traditional 12 month rite of passage can surely agree that some of this time would be better spent doing something other than adult inpatient care.

In a recent survey of child neurology program directors by the Professors of Child Neurology, 39% of the respondents believe that 12 months of adult neurology remain necessary for child neurology residents, while the remaining 59% favored three to nine months of adult neurology training. So while opinions vary widely about the length of adult neurology training, a majority of program directors believe that twelve months of adult neurology training are unnecessary. A strong case can be made for reducing the number of required months by three to six months, and an even stronger case can be made for limiting the number of months assigned to adult inpatient rotations.

Similarly, some of the two years that are now spent in general pediatrics residency might be better utilized on additional training in child neurology or doing a fellowship after residency. We already have two certification tracks that allow only one year of general pediatrics (these permit substitution of either internal medicine or research for one year of pediatrics), so the need for two years of general pediatric training is evidently not absolutely essential for clinical competence in child neurology. In the survey of child neurology program directors, about two thirds of the respondents suggested that 12 to 18 months of general pediatric training may be sufficient to ensure competency as a child neurologist. Almost three fourths of the program directors in this survey also believe that reducing the time spent in training would make child neurology more attractive to potential residents. Reducing the time in pediatric residency amounts to heresy in some circles, and certainly we should not expect residents on abbreviated pathways to be eligible for pediatric board certification. But few child neurologists now practice general pediatrics, and the number of people who obtain and maintain board certification in general pediatrics has dropped sharply in recent years.

Changes in Training Requirements

Even if everyone can agree on the specific changes to recommend, getting major modifications implemented by the organizations that govern training and certification is unlikely to be easy. Altering the curriculum content of the 12 months of adult training is likely to be achieved more quickly than altering the duration of training in adult neurology or general pediatrics. Several changes in child neurology training were recently proposed to the Neurology Residence Review Committee, including limitation of the inpatient ward rotations to six months, allowing rotations spent on adult neuroradiology, neuro-ophthalmology, or electroencephalography to count as adult training, and having the child neurology program director approve the rotation schedule for each resident.

Although these modifications seem relatively modest, their adoption by the Residency Review Committee would alleviate several concerns: they would limit the time spent on adult inpatient rotations, ensure child neurology program director oversight of the residents, and effectively reduce the adult neurology requirement by allowing some rotations that are now considered electives to count toward the twelve adult months. Importantly, these benefits might be achieved without the need for protracted efforts to reach a consensus or extended negotiations with multiple organizations.

Independent Child Neurology Certification?

Some have advocated strongly for the creation of more independent child neurology residency programs with certification limited to child neurology. At first glance, this direct approach seems to solve some of the issues arising from the historic time commitments to adult neurology and general pediatrics. We could tailor our training to match the needs of the child neurologist and replace some of the time now spent in general pediatrics and adult neurology with more relevant activities. The proposal also has a number of practical and philosophical limitations, not the least of which are the time and effort it would take to gain approval of the changes.

Part of the resistance to the idea of separate training programs for child neurologists undoubtedly stems from our inability to anticipate both the positive and the negative consequences of such a change. Would this approach jeopardize the current arrangement with the American Board of Pediatrics? Given the decreasing numbers of child neurologists who obtain and maintain certification in general pediatrics, is this concern even still relevant? Training programs with only a few faculty members may be more vulnerable to these changes. These programs may need to cultivate close relationships with adult neurology departments in order to provide training in topics such as neuroanatomy, neuromuscular disease, pharmacology, and neurophysiology. There is safely in numbers. Would institutions be as likely to provide resources to small programs that are not closely affiliated with a larger neurology or pediatric department?

What is often overlooked in this discussion is that these two approaches are different but by no means mutually exclusive. Modification of the program rules via the Neurology Residency Review Committee could yield prompt benefits and there is strong support in favor of these incremental changes. Changing the certification pathways will take more time, and the consensus needed to make these changes is still lacking. There may be a role for both approaches.

Child Neurology Match

In early 2011, the Executive Boards of the Child Neurology Society and the Professors of Child Neurology unanimously recommended a shift of the child neurology and neurodevelopmental pediatrics residency matches from the San Francisco Matching Program to the National Resident Matching Program (NRMP). The adult neurology match switched to NRMP earlier. The NRMP provides a couple’s match, two separate match tiers, and the option of linking matches to preliminary pediatric programs. The San Francisco Matching Program once provided a three tiered match (one each for medical students, first year pediatric residents, and second or third year pediatric residents), but they planned to scale back to a two tiered match much like that offered by the NRMP. The present match options include positions to start during the same year as the match (must have completed two years of general pediatrics before the start of training in 2012) and positions starting two years after the match. The latter can be “categorical” (preliminary pediatric training in a specific training program is included) or “advanced” (preliminary pediatrics training is not incorporated).

The most serious unanticipated problem in the conversion to NRMP was the refusal (due to start-up timing) of the Electronic Residency Application Service (ERAS) to manage the electronic application submissions, although they did allow the use of their application forms. For the 2012 Match, the application data will be processed by the Association of University Professors of Neurology (AUPN), and ERAS will manage subsequent matches. Although this transition year has provided challenges, we believe that NRMP will provide a stable service with the most flexible options going forward.

As of December, the AUPN had received a total of 187 applications for the child neurology match, 77 of which came from international medical school graduates. Each applicant applied to an average of 19 programs. These preliminary numbers are similar to those of the 2011 San Francisco Match (185 applicants who averaged 20 applications per individual). However, the number of applicants entering the match for the last two years has increased substantially compared to the five prior years (there were 101 applicants in 2005 and 133 in 2006, for example).

Child neurology is an exciting discipline with a constantly expanding body of knowledge. The increased number of child neurology applicants bodes well for the field, as does the potential to provide more focused training. The next generation, however, needs to train for the future, not for the past.