NEUROGENESIS
In the Beginning: How Medical Students Choose (or Do Not Choose) Neurology Kelley A. Humbert, BA and Bernard S. Chang, MD
Editor’s Note: For every neurologist reading these words, there was a time when he or she made the fateful decision to
choose our specialty for a career. This is really the defining moment of “NeuroGenesis,” the process of becoming a neurologist. Yet, despite the future of our profession depending upon inducing the best and brightest medical school graduates to choose neurology, there has been surprisingly little study of this process. The article that follows is a collaboration between one student who recently made that choice and her mentor, exploring that decision. — Editor-in-Chief
“S
o, what are you going into?” The timing of this question about career specialty choice, asked so often of third- and fourth-year medical students in the United States but rarely of first- and second-year students, presupposes that the initial clinical exposure to fields of medicine and surgery rather abruptly and definitively determines a student’s ultimate specialty selection. Although this “love at first sight” discovery may be true for some, a longer process of decision making may be more apt for others. In a sense, career development in neurology, the focus of this journal series, begins even before the commitment to enter the field is made. Surprisingly little is known about the factors that influence students’ choice (or nonchoice) of neurology as the field in which to pursue graduate residency training. Surveys of graduating medical students have revealed a number of considerations when it comes to specialty selection, including the types of clinical situations encountered, academic and intellectual interest in the subject matter, exposure to an influential role model or mentor, personality fit with the field, and what has come to be known in recent years as controllable lifestyle.1,2 With neurologists representing a small minority of established and emerging physicians, however, the particular factors influencing those who decide on neurology have not been extensively investigated. One study analyzed the
characteristics of the institutions that produced the highest and lowest numbers of graduates entering child neurology,3 and another reviewed the factors affecting candidates’ choice of neurology residency program, as well as training opportunities available to students,4 but most of the existing literature has focused on two particular topics: students’ perception of the field and the structure and timing of the neurology clerkship.
Perception Ralph Jozefowicz famously referred to “neurophobia,” the fear of neuroanatomy and neurology he observed among many medical students, in 1994.5 Students report significantly lower perceived knowledge, lower subjective feelings of clinical competence, and higher perceived difficulty of neurology when compared to other specialties studied in the same year of medical school, despite comparable levels of interest in the subject matter.6 Studies have documented a disproportionate degree of discomfort with the field among not only students but also house staff and general practitioners.6–8 The etiology of this specialty-specific fear has been variously attributed to the inherent difficulty of the underlying neuroanatomy that is critical to clinical practice, insufficient teaching that bridges science and practice, diagnostic complexity of neurological disease, and a perceived lack of sufficient bedside teaching and patient exposure.6–8 Given the
View this article online at wileyonlinelibrary.com. DOI: 10.1002/ana.24133 Received Mar 6, 2014, and in revised form Mar 6, 2014. Accepted for publication Mar 6, 2014 From the Department of Neurology, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA.
C 2014 American Neurological Association V 487
ANNALS
of Neurology
widespread burden of neurological disease, there have been repeated calls to improve education and training in a way that diminishes the discomfort of general practitioners and non-neurology professionals when faced with neurological complaints.
Clerkship As of 2005, 93% of American medical schools required a clinical clerkship in neurology, although only 45% required that it be completed in the third year.9 Students in one study expressed preference for a third-year neurology rotation,10 and moving the clerkship from fourth year to third year at one school did result in an increased subjective interest in neurology as a career, although with only a single year of comparison and a small percentage of students ultimately entering the field, the actual number of neurology matches did not change.11 At one school in the United Kingdom, a new, longer clerkship integrating neurology and psychiatry was introduced, with a particular focus on core neurology topics (those encountered in primary care) and neurological diseases with the highest mortality. Students reported subjective knowledge and skill levels similar to those in other clinical disciplines, and neurology was rated the field of most interest along with cardiology. However, respondents in this study continued to rate neurology as more difficult than other specialty clerkships and still experienced less confidence when faced with nonstraightforward neurological complaints as compared to nonstraightforward complaints in other fields.12
Box 1: One Student’s Perspective. I only recently made the decision to pursue a career in neurology. To some degree, all of the considerations in this article played a part in my ultimate choice. Whereas it may have been my right hemisphere giving me that “gestalt” feeling of this being the best field for me, my left hemisphere was working overtime to analyze and find justifications for what I should do and why. Without any relatives battling dementia, traumatic brain injury, or Parkinson disease, and having been fortunate enough to be in good health myself, I find that my inspiration to pursue this field largely stems from the patients I met during my neurology rotations and the unique relationship between them and their neurologists. Watching these interactions, I began hoping that one day I could provide such comfort and support to people whose lives have been forever changed by often stigmatizing neurologic disease and who are seeking a sense of normalcy and acceptance. This social component, combined with my inherent interest and fascination with the workings of the human brain as well as the ever-growing areas of research in neuroscience, led me to choose this field over all others. — K.A.H.
between almost any two fields. We also note choice of practice setting and scope can have impact on a physician’s career experience as choice, which is often underappreciated by because that decision usually occurs later.
that the as much specialty students,
Factors for Consideration Ultimately, each student has a unique set of criteria that ultimately influence his or her decision. Elements such as personal experience with illness or interactions with a notable role model or mentor can have an important impact on specialty choice. Anecdotally, for many students there is the intangible element of a “good fit” in evaluating different specialties, but the components that make up that fit can be elusive. Senior neurologists, whose opinions and experience on other matters are so valued, are the most removed from this early career decision point and may find it difficult to remember or articulate exactly what influenced their own choices. In the absence of solid evidence of what actually does influence medical students’ thinking regarding neurology compared to other specialties, we offer a few considerations below from our own experiences and conversations that may be useful to students considering neurology as a potential specialty choice. In doing this, we fully recognize that highlighting distinctions among specialties presents the risk of introducing or reinforcing unhelpful stereotypes; there is diversity to be found within any specialty and commonalities to be found 488
Neurology Is the Ultimate Cerebral Specialty All fields in medicine involve combinations of thinking and doing, and making a distinction in this regard may seem somewhat prejudicial (in either direction, depending on one’s inclination). However, neurologists generally spend more time rounding, discussing, and cogitating over cases, and with a few notable exceptions, most do not perform procedures on a frequent or regular basis. The field places a traditional emphasis on a logical and concrete diagnostic process that is often remarked upon by outside observers. Students need to decide whether they are a good fit for this kind of specialty. Neurology Is about Only One Organ System, but a Complex One That Touches on Every Other System In the final analysis, the human brain and nervous system are simply unique. For many neurologists, that seems to be what drew them to the field and what keeps them there. Students, however, fresh from just being exposed to all of clinical medicine in its diversity and Volume 75, No. 4
Humbert and Chang: In the Beginning
breadth, need to be comfortable with a decision to focus on the nervous system alone, in one way or another, for their entire careers. Non-neurologists are often surprised, however, at the sheer number and variety of subspecialties within the field, which stem naturally from the anatomical extent and physiological scope of the nervous system. Neurology Involves Longitudinal Clinical Care The outdated reputation of neurology as a therapeutically barren field is now well behind us, but the kernel of truth that remains is that many disorders of the human nervous system are chronic and have no true cure per se. Although the rise of neurointensivists has certainly changed the field’s complexion, many neurologists still spend much of their time managing patients with chronic illness whom they come to know well over long periods of time. This kind of patient–doctor interaction, which is also found in other subspecialties of medicine, and the resulting therapeutic bond that develops appeal to some students more than others. Neurology Is a Natural Field for Research and Teaching A higher proportion of neurologists (about 20%) practices in an academic setting, compared to most other medical specialists. Even within academic medicine, neurology has a particularly strong profile. In a recent review of the faculty at Harvard Medical School, neurology had the highest number of publications per faculty member and the highest h-index of any clinical department. With our knowledge of the underlying mechanisms and therapeutic targets for many neurological diseases still incomplete, there are necessarily close ties between bench and bedside. At the same time, with the perceived difficulty of the subject being quite high among students and nonspecialists, as already remarked upon, there is much opportunity for those interested in teaching at all levels. In the end, no list of discrete considerations can replace the intuitive judgment students must make as to whether neurology is the right field for them, nor can one example (Box 1) highlight the many nuances that go into each individual’s decision-making process. There is, in truth, no substitute for finding good mentors and role models, speaking to neurology residents and faculty, meeting patients afflicted with nervous system disorders, reading avidly from textbooks and journals such as this
April 2014
one, and, as the ancient oracle advised, having a keen sense of self-awareness.
Authorship K.A.H. is a fourth-year student at Harvard Medical School who participated in this year’s neurology residency match. B.S.C. is the editor of the NeuroGenesis series, an epilepsy neurologist, and codirector of the introductory nervous system course for most Harvard medical students.
Potential Conflicts of Interest Nothing to report.
References 1.
Kassebaum DG, Szenas PL. Faqctors influencing the specialty choices of 1993 medical school graduates. Acad Med 1994;69: 163–170.
2.
Dorsey ER, Jarjoura D, Rutecki GW. Influence of controllable lifestyle on recent trends in specialty choice by US medical students. JAMA 2003;290:1173–1178.
3.
Werner RM, Polsky D. Strategies to attract medical students to the specialty of child neurology. Pediatr Neurol 2004;30:35–38.
4.
Adair JC, Rudnicki SA, Boudreau E, et al. Survey of training programs’ needs for promoting neurology and attracting trainees. Neurology 2006;67:936–939.
5.
Josefowicz R. Neurophobia: the fear of neurology among medical students. Arch Neurol 1994;51:328–329.
6.
Schon F, Hart P, Fernandez C. Is clinical neurology really so difficult? J Neurol Neurosurg Psychiatry 2002;72:557–559.
7.
Zinchuk AV, Flanagan EP, Tubridy NJ, et al. Attitudes of US medical trainees towards neurology education: “neurophobia”—a global issue. BMC Med Educ 2010;10:49.
8.
Flanagan E, Walsh C, Tubridy N. ‘Neurophobia’—attitudes of medical students and doctors in Ireland to neurological teaching. Eur J Neurol 2007;14:1109–1112.
9.
American Academy of Neurology. 2005 clerkship directors survey final report. 2006. Available at: https://www.aan.com Accessed January 24, 2014.
10.
Schenkenberg T, Jones CR, Steffens JD, Greenlee JE. Assessing the neurology clerkship: the value of student feedback. Neurology 2004;63:1757–1758.
11.
Dewey RB, Agostini M. Attitudes and performance of third- vs. fourth-year neurology clerkship students. Arch Neurol 2010;67: 548–551.
12.
Ridsdale L, Massey R, Clark L. Preventing neurophobia in medical students, and so future doctors. Pract Neurol 2007;7:116–123.
DOI: 10.1002/ana.24133
489
In the Beginning: How Medical Students Choose (or Do Not Choose) Neurology Kelley A. Humbert, BA and Bernard S. Chang, MD
Editor’s Note: For every neurologist reading these words, there was a time when he or she made the fateful decision to
choose our specialty for a career. This is really the defining moment of “NeuroGenesis,” the process of becoming a neurologist. Yet, despite the future of our profession depending upon inducing the best and brightest medical school graduates to choose neurology, there has been surprisingly little study of this process. The article that follows is a collaboration between one student who recently made that choice and her mentor, exploring that decision. — Editor-in-Chief
“S
o, what are you going into?” The timing of this question about career specialty choice, asked so often of third- and fourth-year medical students in the United States but rarely of first- and second-year students, presupposes that the initial clinical exposure to fields of medicine and surgery rather abruptly and definitively determines a student’s ultimate specialty selection. Although this “love at first sight” discovery may be true for some, a longer process of decision making may be more apt for others. In a sense, career development in neurology, the focus of this journal series, begins even before the commitment to enter the field is made. Surprisingly little is known about the factors that influence students’ choice (or nonchoice) of neurology as the field in which to pursue graduate residency training. Surveys of graduating medical students have revealed a number of considerations when it comes to specialty selection, including the types of clinical situations encountered, academic and intellectual interest in the subject matter, exposure to an influential role model or mentor, personality fit with the field, and what has come to be known in recent years as controllable lifestyle.1,2 With neurologists representing a small minority of established and emerging physicians, however, the particular factors influencing those who decide on neurology have not been extensively investigated. One study analyzed the
characteristics of the institutions that produced the highest and lowest numbers of graduates entering child neurology,3 and another reviewed the factors affecting candidates’ choice of neurology residency program, as well as training opportunities available to students,4 but most of the existing literature has focused on two particular topics: students’ perception of the field and the structure and timing of the neurology clerkship.
Perception Ralph Jozefowicz famously referred to “neurophobia,” the fear of neuroanatomy and neurology he observed among many medical students, in 1994.5 Students report significantly lower perceived knowledge, lower subjective feelings of clinical competence, and higher perceived difficulty of neurology when compared to other specialties studied in the same year of medical school, despite comparable levels of interest in the subject matter.6 Studies have documented a disproportionate degree of discomfort with the field among not only students but also house staff and general practitioners.6–8 The etiology of this specialty-specific fear has been variously attributed to the inherent difficulty of the underlying neuroanatomy that is critical to clinical practice, insufficient teaching that bridges science and practice, diagnostic complexity of neurological disease, and a perceived lack of sufficient bedside teaching and patient exposure.6–8 Given the
View this article online at wileyonlinelibrary.com. DOI: 10.1002/ana.24133 Received Mar 6, 2014, and in revised form Mar 6, 2014. Accepted for publication Mar 6, 2014 From the Department of Neurology, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA.
C 2014 American Neurological Association V 487
ANNALS
of Neurology
widespread burden of neurological disease, there have been repeated calls to improve education and training in a way that diminishes the discomfort of general practitioners and non-neurology professionals when faced with neurological complaints.
Clerkship As of 2005, 93% of American medical schools required a clinical clerkship in neurology, although only 45% required that it be completed in the third year.9 Students in one study expressed preference for a third-year neurology rotation,10 and moving the clerkship from fourth year to third year at one school did result in an increased subjective interest in neurology as a career, although with only a single year of comparison and a small percentage of students ultimately entering the field, the actual number of neurology matches did not change.11 At one school in the United Kingdom, a new, longer clerkship integrating neurology and psychiatry was introduced, with a particular focus on core neurology topics (those encountered in primary care) and neurological diseases with the highest mortality. Students reported subjective knowledge and skill levels similar to those in other clinical disciplines, and neurology was rated the field of most interest along with cardiology. However, respondents in this study continued to rate neurology as more difficult than other specialty clerkships and still experienced less confidence when faced with nonstraightforward neurological complaints as compared to nonstraightforward complaints in other fields.12
Box 1: One Student’s Perspective. I only recently made the decision to pursue a career in neurology. To some degree, all of the considerations in this article played a part in my ultimate choice. Whereas it may have been my right hemisphere giving me that “gestalt” feeling of this being the best field for me, my left hemisphere was working overtime to analyze and find justifications for what I should do and why. Without any relatives battling dementia, traumatic brain injury, or Parkinson disease, and having been fortunate enough to be in good health myself, I find that my inspiration to pursue this field largely stems from the patients I met during my neurology rotations and the unique relationship between them and their neurologists. Watching these interactions, I began hoping that one day I could provide such comfort and support to people whose lives have been forever changed by often stigmatizing neurologic disease and who are seeking a sense of normalcy and acceptance. This social component, combined with my inherent interest and fascination with the workings of the human brain as well as the ever-growing areas of research in neuroscience, led me to choose this field over all others. — K.A.H.
between almost any two fields. We also note choice of practice setting and scope can have impact on a physician’s career experience as choice, which is often underappreciated by because that decision usually occurs later.
that the as much specialty students,
Factors for Consideration Ultimately, each student has a unique set of criteria that ultimately influence his or her decision. Elements such as personal experience with illness or interactions with a notable role model or mentor can have an important impact on specialty choice. Anecdotally, for many students there is the intangible element of a “good fit” in evaluating different specialties, but the components that make up that fit can be elusive. Senior neurologists, whose opinions and experience on other matters are so valued, are the most removed from this early career decision point and may find it difficult to remember or articulate exactly what influenced their own choices. In the absence of solid evidence of what actually does influence medical students’ thinking regarding neurology compared to other specialties, we offer a few considerations below from our own experiences and conversations that may be useful to students considering neurology as a potential specialty choice. In doing this, we fully recognize that highlighting distinctions among specialties presents the risk of introducing or reinforcing unhelpful stereotypes; there is diversity to be found within any specialty and commonalities to be found 488
Neurology Is the Ultimate Cerebral Specialty All fields in medicine involve combinations of thinking and doing, and making a distinction in this regard may seem somewhat prejudicial (in either direction, depending on one’s inclination). However, neurologists generally spend more time rounding, discussing, and cogitating over cases, and with a few notable exceptions, most do not perform procedures on a frequent or regular basis. The field places a traditional emphasis on a logical and concrete diagnostic process that is often remarked upon by outside observers. Students need to decide whether they are a good fit for this kind of specialty. Neurology Is about Only One Organ System, but a Complex One That Touches on Every Other System In the final analysis, the human brain and nervous system are simply unique. For many neurologists, that seems to be what drew them to the field and what keeps them there. Students, however, fresh from just being exposed to all of clinical medicine in its diversity and Volume 75, No. 4
Humbert and Chang: In the Beginning
breadth, need to be comfortable with a decision to focus on the nervous system alone, in one way or another, for their entire careers. Non-neurologists are often surprised, however, at the sheer number and variety of subspecialties within the field, which stem naturally from the anatomical extent and physiological scope of the nervous system. Neurology Involves Longitudinal Clinical Care The outdated reputation of neurology as a therapeutically barren field is now well behind us, but the kernel of truth that remains is that many disorders of the human nervous system are chronic and have no true cure per se. Although the rise of neurointensivists has certainly changed the field’s complexion, many neurologists still spend much of their time managing patients with chronic illness whom they come to know well over long periods of time. This kind of patient–doctor interaction, which is also found in other subspecialties of medicine, and the resulting therapeutic bond that develops appeal to some students more than others. Neurology Is a Natural Field for Research and Teaching A higher proportion of neurologists (about 20%) practices in an academic setting, compared to most other medical specialists. Even within academic medicine, neurology has a particularly strong profile. In a recent review of the faculty at Harvard Medical School, neurology had the highest number of publications per faculty member and the highest h-index of any clinical department. With our knowledge of the underlying mechanisms and therapeutic targets for many neurological diseases still incomplete, there are necessarily close ties between bench and bedside. At the same time, with the perceived difficulty of the subject being quite high among students and nonspecialists, as already remarked upon, there is much opportunity for those interested in teaching at all levels. In the end, no list of discrete considerations can replace the intuitive judgment students must make as to whether neurology is the right field for them, nor can one example (Box 1) highlight the many nuances that go into each individual’s decision-making process. There is, in truth, no substitute for finding good mentors and role models, speaking to neurology residents and faculty, meeting patients afflicted with nervous system disorders, reading avidly from textbooks and journals such as this
April 2014
one, and, as the ancient oracle advised, having a keen sense of self-awareness.
Authorship K.A.H. is a fourth-year student at Harvard Medical School who participated in this year’s neurology residency match. B.S.C. is the editor of the NeuroGenesis series, an epilepsy neurologist, and codirector of the introductory nervous system course for most Harvard medical students.
Potential Conflicts of Interest Nothing to report.
References 1.
Kassebaum DG, Szenas PL. Faqctors influencing the specialty choices of 1993 medical school graduates. Acad Med 1994;69: 163–170.
2.
Dorsey ER, Jarjoura D, Rutecki GW. Influence of controllable lifestyle on recent trends in specialty choice by US medical students. JAMA 2003;290:1173–1178.
3.
Werner RM, Polsky D. Strategies to attract medical students to the specialty of child neurology. Pediatr Neurol 2004;30:35–38.
4.
Adair JC, Rudnicki SA, Boudreau E, et al. Survey of training programs’ needs for promoting neurology and attracting trainees. Neurology 2006;67:936–939.
5.
Josefowicz R. Neurophobia: the fear of neurology among medical students. Arch Neurol 1994;51:328–329.
6.
Schon F, Hart P, Fernandez C. Is clinical neurology really so difficult? J Neurol Neurosurg Psychiatry 2002;72:557–559.
7.
Zinchuk AV, Flanagan EP, Tubridy NJ, et al. Attitudes of US medical trainees towards neurology education: “neurophobia”—a global issue. BMC Med Educ 2010;10:49.
8.
Flanagan E, Walsh C, Tubridy N. ‘Neurophobia’—attitudes of medical students and doctors in Ireland to neurological teaching. Eur J Neurol 2007;14:1109–1112.
9.
American Academy of Neurology. 2005 clerkship directors survey final report. 2006. Available at: https://www.aan.com Accessed January 24, 2014.
10.
Schenkenberg T, Jones CR, Steffens JD, Greenlee JE. Assessing the neurology clerkship: the value of student feedback. Neurology 2004;63:1757–1758.
11.
Dewey RB, Agostini M. Attitudes and performance of third- vs. fourth-year neurology clerkship students. Arch Neurol 2010;67: 548–551.
12.
Ridsdale L, Massey R, Clark L. Preventing neurophobia in medical students, and so future doctors. Pract Neurol 2007;7:116–123.
DOI: 10.1002/ana.24133
489
