Neurology for internal medicine residents: Working towards a national Canadian curriculum consensus

Abstract

Background: Partly due to the absence of a standardized neurology curriculum, internal medicine residents often perceive neurology lowest in terms of the level of knowledge and clinical confidence.

Aims: To compare the learning needs of internal medicine residents with the perceived learning needs of neurology and internal medicine program directors and to integrate these needs by developing a focused nationwide neurology curriculum for internal medicine residents rotating through neurology.

Methods: Medical residents and neurology and internal medicine program directors from programs across the Canada were asked to complete an online survey and to rank an exhaustive list of neurology topics. A modified Delphi approach was used to obtain consensus on the top 20 topics to include in the curriculum.

Results: Over 80% of residents felt their competency in neurology was average or below after completing their neurology rotation. There was very high correlation between the topics ranked by residents and staff. We were able to achieve consensus on 20 topics to be included in a neurology curriculum for internal medicine residents.

Conclusion: Through a modified Delphi approach we were able to produce a neurology curriculum for internal medicine residents rotating through neurology based on the input of program directors across the country.

Introduction

Despite a need for all medical practitioners to have familiarity and comfort with an approach to neurological disorders, neurology is often viewed by students and residents with fear and trepidation (Jozefowicz 1994). Out of a number of medical subspecialties, residents and practitioners perceive neurology lowest in terms of level of knowledge and clinical confidence, and highest in difficulty (Schon et al. 2002). One solution to this problem may be “more and better teaching” that integrates clinical neurology and basic neuroscience, and stresses the “most basic and simple concepts” (Schon et al. 2002). Curriculum-based education has been shown to improve resident performance and confidence in topics within neurology (Schuh & Burdette 2004; Schuh et al. 2007).

In many hospitals across Canada, internal medicine specialists are the most responsible physicians for patients with primary neurological complaints. Therefore, acquiring a solid foundation in the diagnosis and management of common and life threatening neurological disorders during resident training is of paramount importance. Although a national guideline for a neurology curriculum for medical students was devised by the American Academy of Neurology (Gelb et al. 2002), there is no national neurology curriculum for internal medicine residents. Without standardization, neurology curricula for off-service residents are at risk of containing topics of little clinical relevance to non-specialists and of being overly ambitious with regards to the amount of material covered during a brief clinical rotation. Moreover, institutional off-service neurology curricula are rarely developed with input from neurology faculty or the internal medicine residents, whose input can improve the clinical relevance of the material taught.

Our study intends to (1) compare the perceived learning needs of the internal medicine residents with those determined by program directors in neurology and internal medicine and to (2) integrate these needs in the development of a focused nationwide neurology curriculum for internal medicine residents rotating through neurology.

Table

Practice points

Internal medicine residents self-perceived competency in neurology is low both before and after neurology rotations. Learning objectives chosen by program directors for residents closely match residents’ perceived needs. A consensus neurology curriculum tailored for off-service internal medicine residents was achieved and will lay the groundwork for improved education at our institution.

Methods

This study is based on a modified Delphi approach aimed at generating consensus opinion of important topics to include in a nationwide neurology curriculum through an iterative survey of the study participants (Linstone & Turoff 1975). The participants of the survey are the directors of internal medicine programs and neurology programs in University affiliated teaching hospitals across Canada as well as internal medicine residents from the participating institutions. To request participation, medical directors were contacted by email and by phone. Participating general internal medicine program directors were asked to distribute the survey to their residents.

The initial survey was composed of a comprehensive list of all topics in neurology divided into four categories: Neurological Presentations, Investigations, Neurological Disorders, and Management of Neurological Emergencies. The topics were generated by combining the chapter topics from two comprehensive neurology textbooks with additional topics generated by the authors (Aminoff 2008; Bradley 2008). Participants were asked to rate each item on the list using a five point Likert scale (definitely include, possibly include, neutral, possible exclude, and definitely exclude). There was an opportunity for entering free text where participants were asked to include other items that were not included in the survey.

In the first iteration, the individual topics were ranked in order of importance based on the pooled Likert scale data. A rank list was generated separately for program directors and internal medicine residents to allow for comparison. In addition to rating the topic list, those internal medicine residents who had completed a neurology rotation were asked if they had received a neurology curriculum at some point during their rotation. They were then asked to rate their self-perceived skill in neurology before and after completing their neurology rotation as compared to their skill in other medical subspecialties.

For the second iteration of the survey, the detailed rank list generated by the program directors was simplified by grouping similar topics and was then redistributed to all the program directors in neurology and internal medicine. The residents were not involved in the second iteration. Program directors were instructed to generate a list of their top 20 topics to be included in a neurology curriculum based on the first iteration rank list. They were informed that one of the goals of this study was to develop a curriculum that could be taught in 1 month in order to encourage careful selection of high-impact topics that would reflect actual clinical practice. The ideal would be to have one topic covered per day, 5 days per week over 4 weeks, or a total of 20 topics. This number of topics was chosen to be consistent with the length of neurology rotations in most centers. Each Canadian program differs slightly in which subspecialty rotations are mandatory versus elective as well as the length of subspecialty rotations. At the University of Toronto, the internal medicine residents must take at least 1 month of neurology during their training, but many take an additional 1 or 2 months, usually in their 3 years of residency.

Results

Eleven program directors (6 of 16 neurology and 5 of 16 internal medicine) and 32 internal medicine residents (Table 1) responded to the initial survey. 62% of internal medicine residents who had completed a neurology rotation stated that they had received a copy of a neurology curriculum during their rotation, but only 33% felt that the objectives of that curriculum were achieved. Table 2 gives the results of residents’ self-perceived skill in neurology compared to the other medical subspecialties. Prior to their neurology rotation, 91% felt their neurology skills were average or below average. After their rotation, 81% still felt their neurology skills were average or below average.

Table 1.  Resident demographics

Post-graduate year	Number (%)
1	10 (31.3)
2	6 (18.8)
3	14 (43.8)
4	2 (6.3)
5	0 (0)

Table 2.  Internal medicine resident's self-perceived competency in neurology

	Before neurology rotation (%)	After neurology rotation (%)
Best	0	0
Above average	7.1	18.5
Average	42.9	62.1
Below average	48.3	18.5
Worst	0	0

A rank order list of neurology topics based on the pooled Likert scale data from the first iteration of the survey was generated separately by the program directors and residents (Table S1 which can be found online in the supplementary materials accompanying this article). The correlation between program director and resident ranking was very high (correlation coefficient 0.90). There were no examples of significant outlier topics, i.e., ones that were ranked of high importance by program directors but of low importance by residents, or vice versa. Respondents pointed out that there was a large amount of redundancy in the topic list, so the topics were further combined based on similarity.

A total of eight program directors responded to the second iteration of the survey. Table 3 gives the final list of 20 topics representing a combination of the number of respondents listing the topic and the rank order of the topic in each list.

Table 3.  Top 20 neurology topics

Rank	Topics
1	Ischemic stroke
2	Interpretation of patterns of weakness
3	Headache
4	Encephalitis/meningitis
5	Epilepsy
6	Dizziness & vertigo
7	Movement disorders (especially Parkinson's disease)
8	Structural neuroimaging
9	Dementia
10	Aphasia
11	Disorders of consciousness (e.g., prognosis of coma, persistent vegetative state (PVS); brain death determination)
12	Intracerebral hemorrhage
13	Multiple sclerosis and other inflammatory demyelinating diseases of the central nervous system (CNS)
14	Disorders of peripheral nerves
15	Acute spinal cord injury
16	Delirium
17	Neurological complications in critically ill patients
18	Deficiency diseases of the nervous system
19	Disorders of neuromuscular transmission
20	Neurological manifestations of human immunodeficiency virus infection

Table S1 Rank order list of neurology topics after the first iteration of the survey

Rank^a	Topics^b	Staff	Residents
		Rating average^c
1	Ischemic cerebrovascular disease	5.00	4.9
1	Acute ischemic stroke	5.00	4.9
1	Stroke in the young	4.91	4.1
1	Neurological complications of hypertension	4.82	4.58
2	Interpretation of patterns of weakness: e.g., proximal, distal, generalized weakness	5.00	4.77
2	Hemiplegia and monoplegia	5.00	4.29
2	Paraplegia	4.91	4.06
3	Bacterial meningitis	5.00	4.65
3	Viral encephalitis	4.91	4.65
3	Bacterial infections	4.82	4.45
3	Viral infections	4.82	4.45
4	Intracerebral hemorrhage	5.00	4.65
4	Intracranial aneurysms and subarachnoid hemorrhage	4.73	4.58
4	Subarachnoid hemorrhage	4.64	4.42
5	Dizziness & vertigo	5.00	4.55
5	Acute dizziness	4.82	4.55
6	Aphasia	5.00	4.42
7	Multiple sclerosis and other inflammatory demyelinating diseases of the CNS	4.91	4.74
8	Headache	4.91	4.71
8	Headache and other craniofacial pain	4.91	4.42
8	Temporal arteritis	4.91	4.45
9	Delirium and confusional states	4.91	4.55
9	Toxic and metabolic encephalopathies	4.73	4.48
10	Anoxic-ischemic encephalopathy	4.91	4.13
10	Neurological complications of cardiac arrest	4.82	4.45
11	Epilepsy	4.91	4.71
11	Status epilepticus	4.91	4.74
11	Episodic impairment of consciousness	4.82	4.13
12	Structural neuroimaging (magnetic resonance imaging, MRI; computed tomography, CT)	4.82	4.81
13	Movement disorders – Parkinsonism	4.82	4.74
13	Movement disorders – tremor	4.73	4.39
13	Movement disorders	4.73	4.52
14	Stupor and coma	4.82	4.61
14	Unexplained coma	4.82	4.77
14	The neurology of disorders of consciousness (e.g., prognosis of coma, PVS; brain death determination)	4.82	4.35
15	Dementia	4.82	4.45
16	Acute visual loss	4.82	4.45
16	Vision loss	4.73	4.23
17	Neurological complications in critically ill patients	4.82	4.42
18	Disorders of peripheral nerves	4.82	4.39
18	Neurological disorders associated with diabetes	5.00	4.45
19	Neurological manifestations of human immunodeficiency virus infection	4.82	4.39
20	Disorders of neuromuscular transmission (including myasthenia gravis)	4.82	4.35
21	Deficiency diseases of the nervous system (e.g., vitamin deficiencies)	4.82	4.16
22	Cranial neuropathies	4.82	4.19
22	Dysarthria	4.64	4.39
22	Diplopia	4.64	4.52
23	Pupillary and eyelid abnormalities	4.82	3.87
24	Acute spinal cord or cauda equina compression	4.73	4.68
24	Other Spinal cord syndromes (Brown-Sequard, central cord)	4.55	3.97
25	Neurological manifestations of electrolyte disturbances	4.73	4.32
26	Neurological manifestations of acquired cardiac disease and arrhythmias	4.73	4.03
26	Neurological manifestations of infective endocarditis	4.73	4.16
27	Limb ataxia	4.64	3.9
27	Disorders of the cerebellum, including the degenerative ataxias	4.55	4.29
27	Gait disorders	4.55	4.35
28	Neurological disorders associated with connective tissue diseases and vasculitis	4.64	4.29
28	CNS vasculitis	4.64	4.26
29	Nervous system metastases	4.64	3.9
30	Increased intracranial pressure	4.64	4.55
31	Sensory abnormalities of the limbs, trunk, and face	4.55	4.1
32	Paraneoplastic disorders	4.55	3.97
33	Neurological complications of substance abuse	4.55	3.81
34	Neurological manifestations of hematological disorders	4.55	4.19
35	Neurological disorders associated with sarcoidosis	4.55	3.97
36	Acute generalized weakness	4.45	4.45
37	Falls and drop attacks	4.45	4.42
38	Disorders of upper and lower motor neurons (e.g., amyotrophic lateral sclerosis)	4.45	4.29
39	Neurological disorders associated with thyroid disease	4.45	4.13
40	Disorders of the autonomic nervous system	4.45	4.1
41	Neurological complications of cardiovascular surgery	4.45	3.74
42	Fungal infections	4.36	4.19
43	Disorders of nerve roots and plexuses	4.36	4.16
44	Drug-induced disorders of the nervous system	4.36	3.97
45	Neurological complications of chemotherapy and radiation therapy	4.36	3.58
46	Neurological problems of pregnancy	4.36	3.16
47	Cardiac manifestations of acute neurological lesions	4.27	4.19
48	Brain edema and disorders of cerebrospinal fluid circulation	4.27	4.1
49	Dix-Hallpike maneuver	4.27	4.03
50	Vascular malformations	4.27	3.77
51	Otoneurological manifestations of otological disease (e.g., benign paraxysmal positional vertigo, Meneire's disease)	4.27	3.77
52	Neurological complications of organ transplantation and immunosuppressive agents	4.27	3.45
53	Nystagmus	4.18	4.29
54	Angiography by CT and MRI	4.18	4.26
55	Neurological disorders associated with gastrointestinal, liver, or pancreatic diseases (e.g., celiac disease)	4.18	4.06
56	Sleep disorders	4.18	3.48
57	Acute dystonia	4.09	4.35
58	Movement disorders – chorea and atheosis	4.09	4.1
59	Parasitic infections	4.09	4.06
60	Neurological disorders associated with kidney disease	4.09	4.06
61	Intellectual and memory impairments	4.09	3.97
62	Agnosias including neglect	4.09	3.94
63	Head trauma	4.09	3.94
64	Particle repositioning maneuver (Epley's maneuver)	4.09	3.71
65	Disorders of skeletal muscle	4.09	3.65
66	Visual field testing	4.09	3.58
67	Psychogenic neurological disorders	4.09	3.13
68	Neurological causes of bladder, bowel, and sexual dysfunction	4.00	4.06
69	Neurogenic dysphagia	4.00	4.03
70	Primary nervous system tumors in adults	4.00	3.97
71	Prion diseases	4.00	3.94
72	Spinal cord vascular disease	4.00	3.87
73	Other endocrinopathies and the nervous system (e.g., pituitary, parathyroid, and adrenal glands)	4.00	3.87
74	Neurological disorders associated with bone and joint disease (e.g., spinal stenosis, Paget's disease)	3.91	3.74
75	Muscle pain and cramps	3.91	3.71
76	Effects of occupational toxins of the nervous system	3.91	3.35
77	Neurological complications of anesthesia	3.91	3.19
78	Ultrasound imaging of cerebral vasculature	3.91	2.77
79	Peripheral nerve trauma	3.82	3.97
80	Movement disorders – dystonia	3.73	4
81	Sex hormones and the nervous system	3.73	3.23
82	Arm and neck pain	3.64	3.68
83	Movement disorders – tics	3.64	3.61
84	Disorders of bones, joints, ligaments, and meninges	3.64	3.29
85	Lower back and lower limb pain	3.55	3.97
86	Limb apraxia	3.55	3.84
87	Nerve conduction studies	3.55	3.65
88	Spinal cord trauma	3.45	3.87
89	Electroencephalography	3.45	3.45
90	Neurological complications of vaccination	3.45	3.19
91	Caloric testing	3.45	3.06
92	Craniocerebral trauma	3.27	3.87
93	Hearing loss	3.27	3.45
94	Cerebral catheter angiography	3.27	3.16
95	Neurocutaneous syndromes	3.27	3.06
96	Disturbances of taste and smell	3.27	3
97	Electromyography	3.18	3.55
98	Effect of physical agents on the nervous system (e.g., heat, radiation, and altitude)	3.18	2.81
99	Mitochondrial disorders	3.18	2.58
100	Channelopathies	3.09	2.48
101	Neuropsychology	3.00	2.61
102	Uro-dynamic studies	3.00	2.39
103	Audiogram	2.91	2.74
104	Functional neuroimaging (functional magnetic resonance imaging, positron emission tomography, single photon emission computed tomography)	2.82	3.19
105	Neurotoxins of animals and plants	2.82	2.68
106	Marine toxins	2.82	2.58
107	Depression and psychosis	2.82	2.52
108	Behavior and personality disturbances	2.64	2.74
109	Evoked potentials	2.55	2.84
110	Developmental disorders of the nervous system	2.36	2.52
111	Electronystagmogram	2.27	2.58
112	Global developmental delay and developmental regression	2.09	2.29
113	Inborn errors of metabolism of the nervous system	2.09	2.29
114	Transcranial magnetic stimulation	1.91	2.29
115	Intraoperative monitoring	1.73	2.1

Notes: ^aThe topics are ordered by their ranking by staff then by residents.

^bSimilar topics are grouped to minimize redundancy.

^c“Rating average” is on a scale of five indicating how desirable a topic is for inclusion.

Discussion

Greater than 90% of internal medicine residents consider their competency in neurology at or below average prior to their neurology rotation, and this figure only improved slightly after completing their neurology rotation. This not only confirms previously reported findings that neurology is considered a weakness by most medical residents, but also suggests that the education of off-service residents in neurology can be improved. We considered if resident dissatisfaction with teaching could be due to mismatch between teacher and learner perception of important learning objectives. However, our data showed that residents and staff physicians ranked topics similarly, with a correlation coefficient in the first iteration of the survey of 0.90, making such a mismatch an unlikely cause of resident dissatisfaction in teaching. Importantly, we noted that while a large number of resident respondents nationwide said they received a neurology curriculum prior to or during their neurology rotation, only one-third reported that the curriculum's objectives were achieved. We did not ascertain the reasons for this, but suspect one reason for this failure is that current curricula may contain overly extensive objectives not tailored to the short duration of off-service neurology rotations.

Our initial list of neurology topics was very thorough, but contained many redundancies as was pointed out by many of the respondents. We were able to modify the second iteration of the survey by grouping similar topics together. Notably, the individual topics that were eventually grouped together were rated similarly on the 5-point Likert scale after the first iteration of the survey, which minimized any concern that the survey results of the second iteration were invalidated by this strategy. Given the high correlation in the ranking of topics between residents and staff physicians and the absence of any significant outliers, we feel that the final curriculum based on the opinion of staff reflects the interests of the residents. For this reason, we excluded residents from the second iteration of the modified Delphi process, as we felt that interests of residents were highly correlated with staff opinion, and that program directors would have the necessary medical experience and knowledge in education to select the best topics for a neurology curriculum.

The final iteration of the survey produced some surprising results. First, neurosurgical topics (acute spinal cord injury and hemorrhagic stroke) were ranked high by education directors and internal medicine residents. While these topics are often taught to neurology residents by neurosurgical staff during neurosurgical rotations, medical residents depend on their neurology colleagues for their education in these vital areas. Second, many topics that neurology educators may consider essential in a neurology curriculum will invariably not make the 20 topics cut-off (e.g., acute visual loss and acute generalized weakness). Nevertheless, most of these topics were ultimately ranked highly as well, and so individual programs may want to add or substitute topics depending on various factors. For example, many internal medicine curricula contain lectures on infectious meningitis and encephalitis, and so this topic may be dropped from the neurology curriculum for off-service residents to allow for the inclusion of other topics not covered elsewhere.

Our study's major weakness was the poor response rate for the two iterations of the survey. 11/32 (34%) of the program directors responded to the first iteration and 8/32 (25%) to the second iteration of the survey. We attempted to improve this by making direct contact with the individual program directors by phone and by reminder emails sent to the participants. Despite the poor response rates, the individuals who did respond were from separate institutions, providing a national input rather than limiting the input to a single institution, which we believe is a major strength of this survey. There was fairly good correlation between the rank lists generated by the individual respondents, suggesting that additional respondents would unlikely change the final outcome significantly.

At our institution, we have begun to implement part of this curriculum by creating three 1-h formal didactic teaching sessions per week, either in the morning or at lunch. The teaching is shared by three clinical educators. We plan to create Powerpoint presentations of 1-h duration on all the topics in the top 20 list that will be shared by the teachers and be made available to the residents. This will ensure that the same material is taught to all the residents, and will also reduce duplication of labor among the teachers.

Through a modified Delphi approach we were able to produce a neurology curriculum for internal medicine residents rotating through neurology based on the input of program directors across the country. We were also able to show that the program directors and internal medicine residents vary little in their opinion regarding what topics in neurology are most important for internal medicine residents to learn. Future research can attempt to measure the impact of this new curriculum on internal medicine resident educational outcomes. Moreover, a nationwide neurology curriculum also allows for the future development of standardized multi-media teaching tools and standardized lectures that can further improve neurology education across Canada.

Declaration of interest: The authors report no conflicts of interest. The authors alone are responsible for the content and writing of this article.