NEUROLOGY

DEFINITION:Neurology is that branch of medicine concerned with the study of the nervous system in health and disease.

GENERAL OBJECTIVES:On completion of the educational program, the graduate physician will be competent to function as a consultant neurologist. This requires the physician to:

1. Provide scientifically based, comprehensive and effective diagnosis and management for patients with neurologic disorders.
2. Communicate effectively with patients, their families and medical colleagues (particularly referring physicians), and other health care professionals.
3. Counsel patients and others on aspects of prevention of neurological disorders, including risk factors, and genetic and environmental concerns.
4. Maintain complete and accurate medical records.
5. Effectively coordinate the work of the health care team.
6. Be an effective teacher of other physicians (including medical students and house officers), other health care personnel and patients.
7. Be proficient in professional and technical skills related to the specialty.
8. Demonstrate personal and professional attitudes consistent with a consultant physician role.
9. Be willing and able to appraise accurately his or her own professional performance.
10. Be willing and able to keep his or her practice current through reading and other modes of continuing medical education.
11. Be able to critically assess the neurological literature as it relates to patient diagnosis, investigation and management.
12. Be able to participate in clinical or basic science studies as a member of a research team.

These elements of competence are expanded as detailed objectives, for greater clarity, in the following pages. The terms "effective" and "appropriate" are used frequently in these statements. "Effective" is defined for the purpose of this document as "adequate to the efficient solution of the problem". "Appropriate" is defined as "appropriate to the presenting problem(s) and patient attitudes and activity". Throughout this document, the term "nervous system" is understood to refer to the central nervous system, the peripheral nervous system, the neuromuscular junction and skeletal muscle.

The detailed objectives describe minimal standards and in no way exclude the necessity for mastery of additional knowledge, skills or attitudes necessary for the most effective management of patients with nervous system disorders.

SPECIFIC OBJECTIVES:At the completion of training, the resident will have acquired the following competencies and will function effectively as:

Medical Expert/Clinical Decision-Maker

General Requirements

• Demonstrate diagnostic and therapeutic skills for ethical and effective patient care.
• Access and apply relevant information to clinical practice.
• Demonstrate effective consultation services with respect to patient care, education and legal opinions.

Specific Requirements

• Provide scientifically based, comprehensive and effective diagnosis and management for patients with neurologic disorders.
  1. Clinical Skills

For a patient with a neurologic complaint or disorder, the physician will be able to:

• Obtain a complete neurologic history from adults and children obtaining a collateral history where necessary.
• Perform an appropriate physical examination.
• Determine whether a patient's symptoms and signs are the result of an organic or psychological disorder. Where they are due to an organic disorder, the resident must determine whether they result from unifocal, multifocal or diffuse involvement of the nervous system and, where possible, appropriately localize the lesion(s).
• Formulate an appropriate differential and provisional diagnosis.
• Outline an appropriate plan of laboratory investigation.
• Outline an appropriate therapeutic plan.
• Exhibit appropriate clinical judgement in outlining a differential diagnosis and an investigative and therapeutic plan, taking into account matters such as the patient's age, general health, risk and cost of investigative procedures, risk and cost of therapeutic interventions, and epidemiology of the disease.
1. Technical Skills
   • Perform a lumbar puncture, Tensilon testing and caloric testing.
   • Identify and describe abnormalities seen in common neurologic disorders on plain x-rays; myelograms; angiograms and computerized tomography (CT), isotope, magnetic resonance imaging (MRI) and position emission tomography (PET) scans of the neuraxis.
   • With regard to a specific patient or clinical history, evaluates the relevance of a specific report on the following investigative procedures: electroencephalogram; motor and sensory nerve conduction study; electromyography; evoked responses; electronystagmogram; audiogram; perimetry; psychometry; cerebrospinal fluid (CSF) analysis; plain x-ray; myelogram; angiogram; ultrasound and CT, isotope, MRI and PET scans of the neuraxis.
   • Identify and describe gross and microscopic specimens taken from the normal nervous system and from the nervous system of patients affected by the major neurologic disorders.
2. Knowledge

As a basis for clinical competence, the neurologist must be familiar with and able to describe or discuss:

• the clinical features, including presenting signs and symptoms, natural history, and prognosis, for the major neurologic disorders
• the clinical features of the major psychiatric syndromes and their known or postulated neurochemical basis
• the embryological development of the nervous system and how congenital anomalies arise from disorders of this process
• the gross and microscopic anatomy of the nervous system, nerve roots, peripheral nerves, muscles and the vascular system of the nervous system; this includes the recognition of the structures in both anatomical and neuro-imaging formats (when technically feasible)
• the anatomy, composition and physiology of myelin
• the mechanisms underlying the resting membrane potential, conduction of an action potential and synaptic transmission
• axonal transport
• the major neurotransmitters and neuromodulators including their clinical significance
• the role of trophic factors in the nervous system
• the formation and circulation of the cerebrospinal fluid (CSF)
• the biologic basis for the blood-brain, blood-cerebrospinal fluid and blood-nerve barriers, and their clinical importance in health and disease
• cerebral blood flow and cerebral metabolism
• function and dysfunction of the immune system with particular emphasis on the implications for nervous system disease
• the anatomical and physiological basis of consciousness, sleep and wakefulness
• the anatomical and physiological basis of speech, memory, learning and behaviour
• the anatomical and physiological basis of the following systems: special senses, sensory, motor, autonomic, limbic, and reticular activating system
• the physiology of the following major subdivisions of the central nervous system: major cortical regions, basal ganglia, thalamus, cerebellum, reticular activating system, respiratory centres and the limbic system
• the anatomic and physiologic basis of the normal neurological examination taking into account the effect of age
• the pathophysiology of neurologic symptoms and signs in the major, primary and secondary neurologic disorders; (examples of these include seizures, spasticity, tremor, aphasia, etc.)
• the basic principles underlying the interpretation of the major clinical tests such as nerve conduction studies, electromyography, electroencephalography, evoked potentials, perimetry, electronystagmography, audiometry, psychometry and CSF analysis; the indications for, and potential value of and limitations and contraindications for, the tests in any clinical situation where their use is being contemplated
• the indications for, side effects and dosages of the major agents used in neurologic therapeutics
• the mechanism(s) of action of the major drugs used in neurological therapeutics
• the teratogenic effects of the major drugs used in neurological therapeutics
• the mechanism(s) of action of apheresis including the rational for the therapeutic usefulness of the procedure in specific neurological diseases, and the indications and contraindications for its use
• the role of surgery in the therapy of neurological disorders including indications and contraindications for its use
• the role of rehabilitative medicine in the treatment of neurological disorders
• the basic histopathologic reactions which occur in nervous system disorders
• the pathologic changes (gross and microscopic) occurring in the major neurologic diseases
• infectious diseases of the nervous system
• the major bacteria causing nervous system infections including classification, staining characteristics, and antibiotic sensitivities
• the basic principles of clinical genetics
• the basic mechanisms of chromosomal division, and chromosomal abnormalities seen in the major neurological disorders that result from disturbances in these mechanisms
• the patterns of inheritance, where known, of neurological disorders
• the principles underlying and the diagnostic value of gene localization
• the biochemical basis for the major neurologic syndromes resulting from inborn errors of metabolism
• the basic procedures used in clinical epidemiology and the clinical epidemiology of nervous system disorders
• the major neurotoxicologic agents and their effects
• the therapeutic and toxic effects of irradiation on nervous tissue, its role in the treatment of, and its relationship to the production of nervous system disorders

Communicator

General Requirements

• Establish therapeutic relationships with patients/families.
• Obtain and synthesize relevant history from patients/families/communities.
• Listen effectively.
• Discuss appropriate information with patients/families and the health care team.

Specific Requirements

• Communicate effectively with patients, their families and medical colleagues (particularly referring physicians), and other health care professionals in both the inpatient and outpatient settings. The Neurologist will:
  • Communicate effectively and regularly with patients and their families.
  • Be considerate and compassionate in communicating with patients and families, willingly provide accurate information appropriate to the clinical situation, with a reasonable attempt at prognosis.
  • Communicate effectively and appropriately with nurses and paramedical personnel.
  • When ordering investigative procedures, ensure there has been adequate communication about the patient with the person who will actually be doing and/or reporting the diagnostic study.
• Counsel patients and others about aspects of prevention of neurologic disorders, including risk factors, and genetic and environmental concerns. The neurologist will:
  • Recognize that complete patient care requires that, in addition to the need for making a correct diagnosis, a search for risk factors for the disorder be undertaken.
  • Recognize that treatment for a patient with a neurological disorder may require in addition to specific medical and surgical interventions, the elimination of risk factors and genetic counselling.

Collaborator

General Requirements

• Consult effectively with other physicians and health care professionals.
• Contribute effectively to other interdisciplinary team activities.

Specific Requirements

• Be an effective teacher of other physicians (including medical students and house officers), other health care personnel, and patients. The neurologists will:
  • Provide instruction to medical students and more junior physicians at a level appropriate to their clinical education and professional competence.
  • Willingly share knowledge with others with whom they are associated, thus ensuring the most effective delivery of health care to patients.

Manager

General Requirements

• Utilize resources effectively to balance patient care, learning needs, and outside activities.
• Allocate finite health care resources wisely.
• Work effectively and efficiently in a health care organization.
• Utilize information technology to optimize patient care, life-long learning and other activities.

Specific Requirements

• Be proficient in professional skills related to the specialty.
• Demonstrate the following professional skills in time management:
  • Recognize that effective use of time depends upon punctuality.
  • Recognize that effective use of time requires planning.
  • Develop speed as well as accuracy in clinical skills.
  • Reserve time for reading and keeping current with the neurological literature.
  • Establish routines for carrying out regular activities and adhere to them.
• Maintain complete and accurate medical records:
  • Record and maintain a complete and accurate medical record for every patient seen; this record will include the patient's history and the findings on physical examination (including the neurologic examination), a differential diagnosis, a provisional diagnosis, a plan for management, appropriate progress notes, and a comprehensive discharge summary.
• Effectively coordinate the work of the health care team:
  • Organize and supervise the more junior physicians and medical students on a ward and/or consultation service in a manner that ensures the efficient and effective delivery of health care for the patients.
  • Indicate, by the treatment plan, that for the optimal treatment of many patients with neurologic disorder, a team approach is necessary -- members of the team may include nurses, rehabilitation personnel (physiotherapists, occupational therapists, speech therapists, etc.), psychologists, social workers, etc.
  • Identify where an important role(s) can be played by disease focused lay groups with regard to helping the patient and/or family and to facilitate its happening.

Health Advocate

General Requirements

• Identify the important determinants of health affecting patients.
• Contribute effectively to improved health of patients and communities.
• Recognize and respond to those issues where advocacy is appropriate.

Specific Requirements

• Learn about community resources and related patient support groups; provide assistance to access programs (e.g. home care, occupational and physiotherapy, drug plans, application for nursing homes etc) and participate in their activities.
• Educate, be able to generate and access information (e.g. printed material, video tapes web sites) and be available as a resource person to counsel patients effectively on neurological disorders.
• Counsel patients on the importance of taking responsibility for their own well-being and recognise the important determinants predisposing to neurological disorders (e.g. risk factors for transient ischemic attack (TIA) and stroke, teratogenic effects of anti-epileptic drugs).
• Understand the role of national and international bodies(e.g. Alzheimer, Stroke, Multiple Sclerosis Societies) in the promotion of neurological health, and the prevention, detection, and treatment of neurological disorders.

Scholar

General Requirements

• Develop, implement and monitor a personal continuing education strategy.
• Critically appraise sources of medical information.
• Facilitate learning of patients, house staff/students and other health professionals.
• Contribute to development of new knowledge.

Specific Requirements

• Be able to critically assess the neurologic literature as it relates to patient diagnosis, investigation and treatment:
  • Develop criteria for evaluating neurological literature.
  • Critically assess the neurological literature using these criteria.
• Be able to participate in clinical or basic science studies as a member of a research team:
  • Be able to describe principles of good research.
  • Use the above principles, and be able to judge whether a research project is properly designed.

Professional

General Requirements

• Deliver highest quality care with integrity, honesty and compassion.
• Exhibit appropriate personal and interpersonal professional behaviours.
• Practise medicine ethically consistent with obligations of a physician.

Specific Requirements

• Demonstrate personal and professional attitudes consistent with a consulting physician role:
  • Periodically review his/her own personal and professional performance against national standards set for the specialty.
  • Be willing to include the patient in discussions concerning appropriate diagnostic and management procedures.
  • Show appropriate respect for the opinions of fellow consultants and referring physicians in the management of patient problems and be willing to provide means whereby differences of opinion can be discussed and resolved.
• Be willing and able to appraise accurately his/her own professional performances and show that he/she recognizes his/her own limitations with regard to skill and knowledge by appropriately consulting other physicians and paramedical personnel when caring for the patient.
• Be willing and able to keep his/her practice current through reading and other modes of continuing medical education and develop a habit of maintaining current his/her clinical skill and knowledge base through continuing medical education.

CONTENT AND ORGANIZATION OF THE RESIDENCY PROGRAM:

There must be an organized program of rotations and other educational experiences, both mandatory and elective, designed to provide each resident with the opportunity to fulfill the educational requirements and achieve competence in the specialty.

The content and organization of each accredited program in adult or pediatric neurology must be consistent with the specialty training requirements as outlined in the document Objectives of Training and Specialty Training Requirements in Neurology.

Residents must be provided with increasing individual professional responsibility, under appropriate supervision, according to the level of competence in the management of neurological patients.

In addition to offering the components noted in the specialty training requirements all accredited programs in adult or pediatric neurology should offer community-based learning experiences.

RESOURCES:There must be sufficient resources including teaching faculty, the number and variety of patients, physical and technical resources, as well as the supporting facilities and services necessary to provide the opportunity for all residents in the program to achieve the educational objectives and receive full training as defined by the specialty training requirements in neurology.

In those cases where a university has sufficient resources to provide most of the training in adult or pediatric neurology but lacks one or more essential elements, the program may still be accredited provided that formal arrangements have been made to send residents to another accredited residency program for periods of appropriate prescribed training.

Learning environments must include experiences that facilitate the acquisition of knowledge, skills, and attitudes relating to aspects of age, gender, culture, and ethnicity appropriate to neurology.

1. Teaching Faculty

There must be a sufficient number of qualified teaching staff to supervise the residents and provide teaching in the basic and clinical sciences related to neurology.

2. Number and Variety of Patients

The number and variety of patients available to the program on a consistent basis must be sufficient to meet the educational needs of the residents. The program must provide an adequate volume of patients to give experience in the diagnosis and management of the following areas of neurological practice: cerebral vascular disease, epilepsy, multiple sclerosis, neoplastic diseases, neuromuscular diseases, dementia, and metabolic and static encephalopathies.

3. Clinical Services Specific to Neurology
   1. In-Patient

Clinical training must be based on adequate resources to ensure full training in all areas of adult or pediatric neurology and related fields of medicine, pediatrics and surgery. The service must be organized into one or more clinical teaching services. The clinical teaching service must be administered by a chief-of-service to whom the senior resident is directly responsible. Active neurosurgical and psychiatric services must also be available.

Pediatric neurology, under the supervision of certified pediatric neurologists, should be available for all residents registered in the adult neurology program.

2. Ambulatory

Both pediatric and adult in-patient and out-patient teaching services should be integrated as much as possible, in order to provide continuity of observation of patients both in and out of hospital. Organized clinics or other ambulatory care facilities must be available to provide opportunities for pre-admission investigation and post-discharge follow-up of patients in the various areas of neurology. Coordination of out-patient consultation services with those of neurosurgical and psychiatric clinics is highly desirable.

3. Emergency

There must be systematic supervision of residents to ensure expertise in the initial management of all types of emergencies involving neurology. Experience in providing a consultative service is an important feature of such training.

4. Intensive Care

Each resident must gain experience, under appropriate supervision, in the care of critically ill patients presenting neurological problems, under appropriate supervision. Residents in a pediatric neurology program must have access to a neonatal unit.

5. Consultation

An active consultation service, dealing with the neurological complications of systemic diseases in internal medicine, surgery, obstetrics and gynecology, oncology, pediatrics, and psychiatry, should be associated with the program. All residents should participate in consultations as a continuing experience or for a minimum of three months dedicated exclusively to this activity.

6. Community Learning Experiences

Community experiences should be available which provide a learning environment with appropriate supervision and evaluation based on rotation specific objectives. This assumes administrative support and linkages with the program.

4. Supporting Services — Clinical, Diagnostic, Technical
   1. Liaison with Other Specialties and Subspecialties

There must be appropriate liaison with teaching services in diagnostic radiology, internal medicine, neuropathology, pediatrics and psychiatry. There must also be a close relationship with the neurosurgical service.

2. Special Facilities

The program must include specialized staff and facilities in the following diagnostic subspecialties: computerized axial tomography, magnetic resonance imaging, myelography, and angiography; electroencephalography, electromyography, and nerve conduction studies; and radioisotopic diagnosis of neurological diseases. A neuropathology laboratory organized for teaching neurology residents is an essential adjunct to the program. Access to neuro-ophthalmology and neuro-otology units is desirable.

ACADEMIC AND SCHOLARLY ASPECTS OF THE PROGRAM:

The academic and scholarly aspects of the program must be commensurate with the concept of a university postgraduate education. The quality of scholarship in the program will in part, be demonstrated by a spirit of enquiry during clinical discussions, rounds, and conferences. Scholarship implies an in-depth understanding of basic mechanisms of normal and abnormal states and the application of current knowledge to practice.

1. Organized Scholarly Activities

Organized scholarly activities such as journal clubs, research conferences and seminars must be a regular part of the program.

2. Basic and Clinical Sciences Relevant to Neurology

The academic program must include organized teaching in the basic and clinical sciences relevant to neurology. This must include organized teaching in the neurosciences, in particular the relevant aspects of anatomy, biochemistry, pharmacology, physiology, psychology, and pathology. The program may include lectures and seminars, which may be interdisciplinary in nature, teaching rounds, special conferences, assignments of laboratory work, technical demonstrations, and journal clubs. The milieu of scholarship should be enhanced wherever possible by close association between residents and active investigators on the staff.

3. Biomedical Ethics

The academic program must ensure that residents gain an understanding of the basic principles and practice of biomedical ethics as it relates to neurology.

4. Communication Skills

The program must ensure that residents learn effective communication skills for interacting with patients and their families, colleagues, co-workers from other disciplines and students. Clearly defined educational objectives for teaching these skills and mechanisms of formal assessment should be in place.

5. Patient Care Team

Residents must be given opportunities to develop effective skills in collaborating with all members of the patient care team.

6. Teaching Skills

Residents must be given opportunities to develop effective teaching skills by teaching junior colleagues and students, as well as through conference presentations, clinical and scientific reports, and patient education.

7. Management Skills

Residents must be given opportunities to develop skills in management as applied to neurology such as efficient practice and records management and the ethical use of health care resources. Residents should also be prepared for their role as a health care advocate.

8. Quality Assurance/Improvement

The program must provide residents with opportunities to gain an understanding of the principles and practice of quality assurance/improvement. Opportunities should be provided for residents to participate actively in such programs in their hospital departments.

9. Research Opportunities for Residents

There must be a faculty member with the responsibility to facilitate the involvement of residents in research and other scholarly work. The academic program must provide the opportunity for residents to learn biostatistics and the critical appraisal of research methodology and medical literature. Such teaching must include issues related to age, gender, culture, and ethnicity in research protocols and data presentation and discussion. Residents should be encouraged to participate in clinical research during the course of the residency program. 

SPECIALTY REQUIREMENTS:

Adult Neurology

Approved residency training including:

  1.     Basic clinical training.

Pediatric Neurology

Approved residency training including:

PROGRAMS (WITH TRAINING REQUIREMENTS):

Diplomas(Dip):

Six months of approved residency training.

Doctor of Medicine(M.D):

Eighteen months of approved residency training.

Doctor of Philosophy(Ph.D):

Forty eight months(four years)of approved residency training.