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1. Current Management in Child Neurology, Third Edition Education of General Neurologists, Pediatricians, © 2005 Bernard L. Maria, All Rights Reserved and Medical Students in Child Neurology BC Decker Inc Pages 22–24 CHAPTER 4 EDUCATION OF GENERAL NEUROLOGISTS, PEDIATRICIANS, AND MEDICAL STUDENTS IN CHILD NEUROLOGY ROGER A. BRUMBACK, MD Neurologists, by virtue of their expertise in the anatomy, physiology, pathology, and pharmacology of the nervous system, are logically the principal medical practitioners to care for infants, children, and adolescents with neurologic disease or disability. Unfortunately, many have been loathe to undertake this challenging task.This is in part because of a sense of inadequacy in dealing with this population,often resulting from a lack of adequate preparation and training. Thus,it is important for all neurology training programs to ensure appropriate pediatric neurology education for all trainees, regardless of subsequent specialization. Unfortunately, time for study in any particular area has become a particular dilemma for training programs, while simultaneously the diagnostic and therapeutic options in neurology continue to expand almost exponentially. Currently,the Accreditation Council for Graduate Medical Education (ACGME) Residency Review Committee (RRC) for Neurology requires only a 3-month exposure to pedi- atric neurology during a general neurology residency training program. A March 1998 survey of 15 university-afﬁliated neurol- ogy training programs (representing a broad geographic distribution in the United States and Canada) was con- ducted to determine the length of pediatric neurology expo- sure. Of the 15 programs, only two required 4 months of pediatric neurology training, one program required just 2 months, and the other 12 provided the minimum of 3 months.Most programs provided the entire pediatric neu- rology experience in a single time block, usually during the second year of training. The experience consisted of a mix- ture of outpatient and inpatient exposures, often heavily weighted toward the latter. Outpatient experience was usually two or three half-day clinics per week.Only one pro- gram required additional outpatient experience in pediatric neurology beyond the experience required by the ACGME Residency Review Committee. In all other programs, any additional training in pediatric neurology consisted of didactic formats such as grand rounds and experiences on- call at night or on weekends, usually through an emergency department and usually without a pediatric neurology attending immediately available. With such limited exposure to pediatric neurology problems while in training, expertise in complex diagnos- tic or therapeutic dilemmas cannot and should not be expected from the general neurologist. More efﬁcient and effective use of the allotted time for pediatric neurology With more than 80 million people under 20 years of age in the United States, several million of whom are affected by neuro- logic problems, it is impractical for treatment to be provided solely by the thousand fully trained and practicing child neurol- ogists. Yet a large number of medical students graduate without formal neurology experience. Neurology training programs need to ensure appropriate pediatric neurology education for all trainees, regardless of subsequent specialization, and it is imper- ative for pediatricians to understand and handle common and basic neurologic problems.
Current Management in Child Neurology, Third Edition Education of General Neurologists, Pediatricians, © 2005 Bernard L. Maria, All Rights Reserved and Medical Students in Child Neurology BC Decker Inc Pages 22–24 24 / Clinical Practice Trends and just 1,000 child neurologists, this is not practical. However, child neurologists need to take a more active role in the neuroscience (and physical diagnosis) courses taught to all ﬁrst- or second-year medical students, describing the approach to a child with neurologic problems and the basics of some of the unique pediatric neurologic problems as noted in the sections above. Child Neurology for All Physicians All physicians need to adopt an attitude of advocacy for infants, children, and adolescents with neurologic prob- lems and must be strident in demanding access to the therapeutic, rehabilitative, and educational resources necessary to maximize a patient’s potential function. This means all physicians must develop an awareness of pediatric neurologic problems and then be vocal in sup- port of the well-being of any pediatric patient with neu- rologic problems. Suggested Readings Bergen DC. World Federation of Neurology Task Force on Neurological Services. Training and distribution of neurol- ogists worldwide. J Neurol Sci 2002;198:3–7. Hooker J, Eccher M, Lakshminarayan K, et al. Neurology train- ing around the world. Lancet Neurol 2003;2:572–9. Maria BL, English W. Do pediatricians independently manage common neurologic problems? J Child Neurol 1993;8:73–7. Painter MJ, Capute A, Accardo P. Subspecialization in the care of children with neurodevelopmental disabilities. J Child Neurol 2001;16:131–3. Palmer FB, Percy AK, Tivnan P, et al. Certiﬁcation in neurode- velopmental disabilities: the development of a new subspe- cialty and results of the initial examinations. Ment Retard Dev Disabil Res Rev 2003;9:128–31. Ringel SP, Vickrey BG, Keran CM, et al. Training the future neu- rology workforce. Neurology 2000;54:480–4. Silverstein FS.Expanding the scope of child neurology for the 21st century. Curr Opin Neurol 1999;12:133–6. of neurodevelopmental disabilities was approved for those child neurologists with expertise in chronic neurologic disabilities. Unfortunately again, only a few dozen child neurologists have qualiﬁed for this certiﬁcation. On the basis of the prevalence of neurologic problems confronting the pediatrician, it seems wise for the neu- rology community at large to reexamine its relationship to pediatric residency training programs. This takes on increasing importance as unproven and potentially harmful treatment approaches proliferate (particularly aided by the ease of disseminating misinformation over the Internet). Even where child neurologists are scarce, general neurologists trained as indicated above can be an educational resource for pediatric training programs. Particular importance should be placed on training related to the basics of neurologic examination and iden- tification of neurologic signs, epilepsy diagnosis, and localization of function within the cerebral hemispheres. This also will help pediatric trainees better understand what they “don’t know” and result in more appropriate neurology referrals. Child Neurology for the Medical Student The accreditation standards for medical schools of the Liaison Committee on Medical Education (LCME) do not mention neurology.Thus,it is not surprising that only a few medical schools have required neurology clerkships and that a large number of medical students graduate without any formal neurology experience. Although pediatric clerkships are mandated by the LCME, as noted above, the scarcity of academic child neurologists and the plethora of other subspecialty areas in pediatrics makes experiences in pediatric neurology even less likely.Often medical students interact with child neurologists only during inpatient con- sultations, which constitute a small part of the patient care activity of any child neurologist.It would be preferable that medical students have an opportunity to work with child neurologists in their ofﬁce practices; however, with more than 25,000 third- and fourth-year U.S. medical students
Education of General Neurologists, Pediatricians, and Medical Students in Child Neurology / 23 training could make general neurologists more comfort- able with the routine pediatric neurologic challenges they might face.For example,most pediatric neurology practice is outpatient-oriented, whereas most training programs continue to emphasize inpatient bedside teaching. Although this can be effective in teaching about complex pediatric neurology problems (eg, neurodegenerative or neurometabolic diseases), these are not likely to be the type of pediatric neurology problems a general neurologist would manage. Almost certainly, such complex cases, if cared for at all, would be handled by a general neurologist in consultation with a pediatric neurologist (possibly one with further fellowship experience in the problem at hand). In terms of the more common pediatric neurologic problems (eg, headaches, learning disabilities, or language disorders) handled in the general neurologist’s practice,the inpatient model is a poor one for both management and teaching purposes. More appropriately, the general neurologist should be provided a continuing outpatient experience, similar to the longitudinal clinic experiences with adult patients. In this manner, there would be the opportunity to under- stand the complex nature of pediatric neurologic disor- ders and their changing nature in the context of the developing child. In fact, because the basic principles of neuroanatomic localization, neurophysiology, neu- ropharmacology, and neuropathology are similar in pedi- atric and adult populations, the curriculum content for the child neurology portion of the training program should emphasize developmental issues, which permeate the diagnostic and treatment decisions in child neurol- ogy. Neurology trainees must learn a developmental approach to the history, acquiring a knowledge of the appropriate developmental milestones, how those skills signify maturation of the nervous system, and how the loss of or failure to attain those skills reflects nervous system dysfunction. The neurologist can then be made aware of unique pediatric neurologic problems such as pediatric epilepsies (ie, absence epilepsy, juvenile myoclonic epilepsy, Lennox- Gastaut syndrome, infantile spasms, and febrile convul- sions); childhood conditions confused with epilepsy (ie, breath-holding spells, night terrors, syncope, or benign paroxysmal vertigo); childhood headaches; neonatal dis- orders (ie, hypoxic-ischemic encephalopathy of the new- born, neonatal seizures, intraventricular hemorrhage, and ﬂoppy infant syndrome); learning, language, and develop- mental disabilities; mental retardation; attention-deﬁcit hyperactivity disorder (ADHD); pervasive developmental disorder (ie, autism); disorders of hearing and vision; childhood neuromuscular disorders (ie, Duchenne’s mus- cular dystrophy, spinal muscular atrophy, and childhood dermatomyositis); and childhood neurogenetic diseases. In addition, the neurology trainee must learn a differ- ent approach: properly eliciting the history and perform- ing a physical examination of a pediatric neurology patient. Instead of obtaining most historical information directly from the patient, the history must be garnered from the child’s guardians or other informants (which is not too dissimilar to what must be done in dealing with aphasic or demented adults in geriatric neurology). The notion that dealing with the child with neurologic impair- ment is a “veterinary” experience needs to be discarded. Similarly, neurology trainees must understand that the “head-to-toes cranial-nerves-to-Babinski”approach of an adult neurologic examination will not often succeed in a young child. The examination must be child-directed rather than physician-directed and is an opportunistic affair. Observation of the child interacting with parents or during play gives valuable information about movement of muscles of facial expression, eye movements, balance, coordination,postural tone,and strength,and the presence of involuntary movements, ataxia, or even sensory distur- bances such as visual or hearing impairments (obviating the need for formal examination, which often results in an unhappy and uncooperative child and family). Child Neurology for the Pediatrician Surveys have clearly indicated that more than 10% of the presenting complaints to a pediatrician’s ofﬁce relate to neurologic problems (when learning and behavioral dis- orders are included as neurologic conditions). However, with more than 80 million people under 20 years of age in the United States and, therefore, with several million of them affected by neurologic problems,it would be imprac- tical for their treatment to be provided solely by the thou- sand fully trained and practicing child neurologists. Thus, it is imperative for pediatricians to understand and handle common and basic neurologic problems. Unfortunately, pediatric residents are currently not required to have pedi- atric neurology training experience. Instead, the ACGME Residency Review Committee for Pediatrics allows the pediatric resident to elect four 1-month experiences from among 11 subspecialties, one of which is pediatric neurol- ogy. Even in those situations in which pediatric residents would elect a pediatric neurology rotation, the scarcity of child neurologists in academic centers often makes this impractical. In partial response, a pediatric subspecialty of developmental-behavioral pediatrics has evolved to eval- uate and treat most children with chronic neurologic prob- lems (except severe epilepsy and neuromuscular diseases). The curriculum for this subspecialty also does not include mandated exposure to pediatric neurology. At about the same time that this developmental-behavioral pediatrics subspecialty was approved, a child neurology subspecialty Current Management in Child Neurology, Third Edition Education of General Neurologists, Pediatricians, © 2005 Bernard L. Maria, All Rights Reserved and Medical Students in Child Neurology BC Decker Inc Pages 22–24