PCN Spring 2014 Report

By Philip L. Pearl, MD

Phillip Pearl, MD

The PCN had an opportunity to review several key areas in academic child neurology during the 2013 annual meeting in Austin. Training Program Directors should be aware that the new ACGME Program Requirements take effect July 1, 2014 and include substantive revisions pertaining to the sponsoring institution, program director’s role and support, faculty, curriculum, and evaluations. In brief, the sponsoring institution must provide at least 20% time and funding support for the program director, with an additional 1% per resident. This brings child neurology in line with our adult counterparts. The sponsoring institution must provide financial support for a program coordinator as well. The program director is mandated to monitor resident stress, approve the adult neurology rotations, and attend at least one national program director meeting annually. Key physician faculty must have current ABPN certification (or possess equivalent qualifications), and a minimum faculty-to-resident ratio of 1:1 must be maintained within the section of child neurology. Faculty must participate regularly in conferences and demonstrate broad involvement in scholarly activity.

The revisions that will most impact our trainees reside in the adult neurology training. Twelve months of adult neurology will be continued, do not need to be contiguous, and are to be comprised of six months on inpatient rotations (defined as requiring > 50% of time managing inpatients), three months of outpatient clinical rotations, and three months of electives. The electives offer wide latitude and neurologic subspecialty areas, including neuroradiology, neuropathology, and neurophysiology, while previously off limits to count as adult neurology months, are included. Clinical electives could include psychiatry, genetics, or neuro-intensive care. This helps to solidify training in general neurology while also promoting special interests and directed career development.

The standardized clinical examination for ABPN certification, which replaced the prior Part II Oral Examination, must be done within the training program, with completion of at least two by the end of the second neurology year and all five prior to the final month of training. These should be five first-patient encounters under direct observation of the following scenarios: neuromuscular, neurocritical care, neurodegenerative, outpatient setting, and adult neurologic disorder. At least one of these patients must be less than two years of age.

ABPN pass rates will be formally factored into program evaluations, so that at least 75% of a program’s eligible graduates from the preceding five years who took the examination for the first time must pass. In programs with fewer than five graduates in the past five years, at least 75% of the five most recent graduates who took the exam must have passed.

The PCN has moved forward with development of a curriculum which was ably jump started by the edition of Seminars in Pediatric Neurology organized by Rob Rust. The Executive Committee has collected first drafts of objectives in nearly all topics and is currently editing them to prepare a document which will be distributed among the membership for further input. Simultaneously, the curriculum will be linked to cases that continue to be collected for the CNS Case Sharing Website, initially established by Mickey Segall, Barry Kosofsky, and Joe Pinter and now being promoted by David Hsieh of the CNS Electronic Communications Committee. Ira Bergman has carefully prepared a series of detailed real world cases, loaded with radiographic images, EEG samples, and laboratory results, offering multiple options for correct (and, wisely ID’d, “ill-advised”) patient evaluation and management. The cases span from encephalitis to stroke, epilepsy, neoplastic, and demyelinative disease among others and will be an outstanding contribution. Milestones development, spearheaded by Pat Crumrine and David Urion, and others including PCN Councilor Howard Goodkin in epilepsy, will complement the content- and case-based curriculum. Implementation of milestones for child neurology is expected July 2015. These will be organized into global domains (e.g. history taking), disease domains (e.g. headache, stroke), and procedural domains (e.g. imaging, EEG, lumbar puncture)and will be reported as falling in five taxonomic levels: novice, advanced beginner, competent, very competent, and expert.

Last summer the PCN surveyed its membership regarding the “home base” for child neurology programs, i.e. adult neurology vs pediatrics. This was initiated following several queries as to the optimal placement for child neurology. This could be viewed as a natural extension of the historical dilemma, or perhaps privileged position, of our subspecialty being at the fulcrum of pediatrics and neurology. The recent debate regarding adult neurology training for child neurologists, led by Don Gilbert and others in thoughtful remarks made during prior PCN and AAN meetings, highlights this question. The survey results were presented during the fall meeting, and indicated an almost even split between whether programs were primarily based in neurology or pediatrics departments. A slight majority identified neurology as their primary academic affiliation (54 vs 46%), whereas a similar majority identified pediatrics as their primary clinical affiliation (55 vs 45%). Factors that may be considered advantages for academic affiliation, e.g. support for scholarly activity, shared training programs, financial support for clinical activities, synergistic research activities, and faculty career development, were reported at similar levels whether programs were placed within neurology or pediatrics. Examples of specific comments cited as problems were lack of support for scholarly activities, a Dean’s tax, and inequity for pediatric neurology reimbursement compared to adult. Overall, when members were asked whether they would change their affiliation, nearly 80% would not (Figure).

Deborah Hirtz provided an update on NINDS activities vis a vis child neurology, with appropriations reported of an approximate 5% decrease in funding. Currently enrolling studies of interest to the community included thrombolysis in pediatric stroke, prednisone and deflazocort in Duchenne muscular dystrophy, early biomarkers of autism in infants with tuberous sclerosis, neurodevelopmental effects of antiepileptic drugs, placebo controlled trials in prophylaxis of childhood migraine, NeuroNEXT SMA biomarkers, preterm erythropoietin neuroprotection trial, and the ADAPT study for severe pediatric traumatic brain injury. Questions may be directed to Deborah at Hirtz@ninds.gov and we look forward to more updates during the fall meeting in Columbus.

The PCN continues to monitor the Match with the able leadership of Harvey Singer; a combined PCN-CNS committee now administrates the Match. Program directors are reminded that programs cannot fill positions outside of the Match unless the applicant fails to match for a same year position, or if there is an unexpected vacancy due to a matched applicant withdrawing immediately preceding the July 1 start date.

The PCN has also joined forces with the CNS to develop the newly established Blue Bird Circle Clinic Award for Outstanding Child Neurology Training Program Director, enabled by the generosity of the Baylor program and the hard work of Gary Clark. The eligibility criteria are:

  • Nominees should be a current or former child neurology residency program director.
  • The award recipient should have demonstrated leadership and vision in local program development, curriculum development, innovation in teaching methods, or training requirements.
  • The awardee should inspire in trainees and colleagues alike a passion for the practice of child neurology. Nominees must be living at the time of selection.

Last year there were five outstanding nominations and Harvey Singer from Johns Hopkins was selected. Nominations for awards are now being recruited and may be made by sending a letter of support and the nominee’s CV to the CNS National Office.

Active members of the PCN are, as written in the Bylaws, current (or previous) heads of divisions/units or training directors with accredited residency programs in child neurology or neurodevelopmental disabilities. The PCN is the body of training program directors in child neurology (analogous to the CNPD in adult neurology), and ALL training program directors are invited to join, attend the annual meeting (always held the Wednesday afternoon prior to the opening reception of the annual CNS meeting), and become involved in the committees and work of the organization. Please say hello and get involved. I am grateful for the work of the Executive Committee: Suresh Kotagal (Secretary-Treasurer), Amy Brooks-Kayal (Councilor), Howard Goodkin (Councilor), David Urion (Councilor), and Bruce Cohen (Past President), and the great assistance by Sue Hussman, Emily McConnell, and Roger Larson from the CNS National Office.