Journal of
News and views
Neurology © Springer-Verlag 1992
J Neurol (1992) 239 : 297-298
Neuroscience for clinicians The majority of junior neurologists in the United Kingdom - and in many other European countries - achieve their post-graduate education by serving time both in regional neurology departments, where small numbers of "general neurologists" see large numbers of patients, and in one of the supra-regional centres of excellence where, it is commonly held, the reverse obtains. No one plans a career in any strict sense: positions in different hospitals are abandoned, acquired or traded in an effectively random order, depending almost entirely on when incumbents choose to move (or be moved) and on the effects of senior appointments eventually filtering through the system. It is a game wherein all the participants are able to claim they have no professional security, no indication of where they might find themselves a few months hence, and no idea where their next Ecu will come from. Yet there are (probably) only a very few casualties among the committed, and job security is of course a relative term only truly understood by those outside medicine who have felt the chill winds of genuine exposure to market forces. And although current National Health Service reforms in the United Kingdom will have an unpredictable effect on post-graduate medical training, and siren calls for structured training programmes can periodically be heard, the current system essentially works - and, it may be said, has delivered to world neurology over the years many outstanding clinicians. More difficult has been the issue of neuroscientific education for clinicians. Into their self-designed training careers, the trainees must now fit a period dedicated to neurological research leading to a doctoral thesis. Such positions are more often informally negotiated than publicly advertised and competitively acquired, and the study may range from the wholly clinical to the purely scientific. This spell clearly allows them a special insight into their chosen areas, but by no means will furnish them with a broad and balanced neuroscience education. Does this matter? It might be argued that such an education should be low in the list of training priorities: Sir Theodore Fox wrote over 25 years ago [1]: "To doctors the gathering of knowledge for its own sake seems an academic extravagance. They know, moreover, that in practice a lot of knowledge, like a little, can be a dangerous thing. The patient may well be safer with a physician who is naturally wise than with one who is artificially learned." Whilst it is easy to agree with the underlying sentiment he articulates, to argue from this precept against continued formal scientific education would be a specious misinterpretation founded upon little more logic than Mark Twain allowed the unwashed Huckleberry Finn: "soap and education are not as sudden as a massacre, but they are more deadly in the long run". It is, after all, difficult to identify a clinical field so rapidly changing in its scientific base as neurology. The remarkable contributions of genetics - virtually solving the molecular background to Duchenne muscular dystrophy, X-linked spinomuscular atrophy, familial periodic paralysis, Thomsen's disease, and now (almost) myotonic dystrophy; the appearance and new biological understanding of numerous infectious neurological conditions - HIV, Lyme disease, prion-related disorders among others; the dramatic advances in the toxicology and pharmacology of Parkinson's disease and other movement disorders; the potential contribution of neuronal transplantation to the treatment of these conditions, and of glial
transplants to the repair of demyelinating lesions; mitochondrial cytopathies; paraneoplastic disorders; excitotoxic injury. Fundamental changes in all these areas have occurred in the time since most junior doctors currently gracing the middle rungs of the neurology training ladder last received any formal neuroscientific education as pre-clinical undergraduates up to 14 or 15 years ago. And for those of a scientific bent who have at least attempted to follow developments, the traditional lack of intercourse between basic neuroscientist and clinical neurologist, the geographical concentration of the former in a handful of universities, and the exacting requirements of clinical training posts have often combined to frustrate their curiosity. Study leave to attend expensive scientific symposia, which are neither intended nor structured to fulfil a primary educational role, is at best begrudged, often denied, and the tyro must resort to covert and furtive nocturnal incursions into Trends in Neurosciences. This perceived gap in postgraduate neurology training in the United Kingdom provided the background and justification for the recent Neuroscience for Clinicians meeting, organised by the CoEditor of this journal and funded generously and with great foresight by the Guarantors of Brain. Seventy neurologists mostly junior, some less obviously so, from Britain and continental Europe - were addressed and informed by 20 or more scientists of eminence representing a broad range of disciplines. The format was conservative - some might say reactionary: a smallish college room, no videos, no gimmicks, double projection available only to Fellows of the Royal Society (or does by memory mislead me?), a taxing 11 or 12 short lectures a day. But there was an air of informality - to paraphrase the host and organiser, many speakers exhibiting a fine disregard for their titles - which blended easily with the intimacy afforded by the surroundings and the manageable number of participants. Broad neuroscientific themes had been employed to harness related but disparate presenters; the tempting trap of arranging a stunning but random (and ultimately unsatisfying) display of intellectual fireworks was carefully avoided, and the overall pattern was of a coordinated and discriminating exposde of much that is good in neuroscience in Britain. The programme highlighted two areas, "systems" neuroscience and cellular neurobiology, which have not only witnessed remarkable advances in recent years, but which, moreover, have lately seen increasingly fruitful relationships with clinical neurology - in the former area, happily ending a near-divorce of several decades' duration, while in the latter, forming a new union which is likely to have exciting and dramatic future implications for the practice of neurology. "Systems neuroscience" underpinned the first day's talks, ordered to reflect a template for clinical neuroscience, progressing from molecules via mechanisms to disease. The Molecular Basis of Memory (John Rawlins, University of Oxford) was followed by an account of memory systems and models (Dr. Alan Baddeley, University of Cambridge), before the baton was handed on to one of the few clinicians to speak, Dr. John Hodges, University Lecturer in Neurology, Cambridge. Tripping lightly around the limbic system, Dr. Hodges used clinical illustrations of a variety of amnestic conditions to provide a rdsum6 of current thinking on the anatomy of memory and its disorders. Aspects of visual neuroscience and perception were described by Professor Zeki (University College, London), Professor Humphries (Department of Cognitive Psy-
298 chology, University of Birmingham), and Dr. John Marshall (Radcliffe Infirmary, Oxford), while the remainder of the day included mechanisms and therapy of hearing impairment (Dr. Moore, University of Cambridge); pain (Professor Wall, University College, London); mathematical paradigms of movement and its neural control (Dr. Wing, University of Cambridge); primate sensorimotor systems and their organisation (Dr. Roger Lemon, University of Cambridge); and current and future strategies for functional rehabilitation after neural damage (Professor Brindley, Institute of Psychiatry, London). The second day's theme was cellular neurobiology. James Fawcett (University of Cambridge) opened the proceedings with a review of regeneration in the central nervous system, followed by Professor Walsh (University of London) on the molecular basis of neural development and repair. Professor Martin Raft (University College, London) spoke on the fundamental importance of apoptotic cell death, and what prevents it. The potential - biological and medical - of neural (Steve Dunnett, University of Cambridge) and glial (Bill Blakemore, University of Cambridge) cell transplants was discussed, while Dr. Tim Cheek (University of Cambridge) spoke on signal transduction in the nervous system. Professor Richard Frackowiack filled an unexpected breach in the programme with a discussion of positron emission tomography and its role in functional imaging of brain order and disorder. Dr. Michael Sofroniew (University of Cambridge) summarised mechanisms of neuronal degeneration and injury, and the programme was completed with two lectures on clinical and molecular neurogenetics by Dr. Kay Davies (University of Oxford) and Professor Anita Harding (Institute of Neurology, London).
Was the meeting a success? It was abundantly clear that all who attended had enjoyed the proceedings but, more than this, felt they had left a little more educated - in Mark Twain's terms, a little less unwashed - than they had arrived. It is hard to imagine how otherwise its success might be judged. Of course, minor details might be alterable - a minority felt that one or two sessions might bear a more practical emphasis; other appealed for a little more leavening. But such alterations represent details: what is surprising (although perhaps it should not be) is that after one outing, the meeting appears to have become indispensible and reversion to the status quo unthinkable. Ramon y Cajal [2] once wrote "Grey matter abounds in countries with grey skies". Regardless of the veracity and wisdom of this particular observation, it is a truism that to possess grey matter is one thing, to use it quite another. Neuroscience for Clinicians has exposed and filled a significant and widening breach in the landscape of postgraduate neurological education in the Britain. Nell Scolding, Cambridge, UK
Reference 1. Fox T (1965) Purposes of medicine. Harveian oration, 1965. Reprinted in The Lancet (1965) I : 801 2. Ramon y Cajal (1920) Charlas de cafe. Translated by FH Garrison
News and views
Neurology © Springer-Verlag 1992
J Neurol (1992) 239 : 297-298
Neuroscience for clinicians The majority of junior neurologists in the United Kingdom - and in many other European countries - achieve their post-graduate education by serving time both in regional neurology departments, where small numbers of "general neurologists" see large numbers of patients, and in one of the supra-regional centres of excellence where, it is commonly held, the reverse obtains. No one plans a career in any strict sense: positions in different hospitals are abandoned, acquired or traded in an effectively random order, depending almost entirely on when incumbents choose to move (or be moved) and on the effects of senior appointments eventually filtering through the system. It is a game wherein all the participants are able to claim they have no professional security, no indication of where they might find themselves a few months hence, and no idea where their next Ecu will come from. Yet there are (probably) only a very few casualties among the committed, and job security is of course a relative term only truly understood by those outside medicine who have felt the chill winds of genuine exposure to market forces. And although current National Health Service reforms in the United Kingdom will have an unpredictable effect on post-graduate medical training, and siren calls for structured training programmes can periodically be heard, the current system essentially works - and, it may be said, has delivered to world neurology over the years many outstanding clinicians. More difficult has been the issue of neuroscientific education for clinicians. Into their self-designed training careers, the trainees must now fit a period dedicated to neurological research leading to a doctoral thesis. Such positions are more often informally negotiated than publicly advertised and competitively acquired, and the study may range from the wholly clinical to the purely scientific. This spell clearly allows them a special insight into their chosen areas, but by no means will furnish them with a broad and balanced neuroscience education. Does this matter? It might be argued that such an education should be low in the list of training priorities: Sir Theodore Fox wrote over 25 years ago [1]: "To doctors the gathering of knowledge for its own sake seems an academic extravagance. They know, moreover, that in practice a lot of knowledge, like a little, can be a dangerous thing. The patient may well be safer with a physician who is naturally wise than with one who is artificially learned." Whilst it is easy to agree with the underlying sentiment he articulates, to argue from this precept against continued formal scientific education would be a specious misinterpretation founded upon little more logic than Mark Twain allowed the unwashed Huckleberry Finn: "soap and education are not as sudden as a massacre, but they are more deadly in the long run". It is, after all, difficult to identify a clinical field so rapidly changing in its scientific base as neurology. The remarkable contributions of genetics - virtually solving the molecular background to Duchenne muscular dystrophy, X-linked spinomuscular atrophy, familial periodic paralysis, Thomsen's disease, and now (almost) myotonic dystrophy; the appearance and new biological understanding of numerous infectious neurological conditions - HIV, Lyme disease, prion-related disorders among others; the dramatic advances in the toxicology and pharmacology of Parkinson's disease and other movement disorders; the potential contribution of neuronal transplantation to the treatment of these conditions, and of glial
transplants to the repair of demyelinating lesions; mitochondrial cytopathies; paraneoplastic disorders; excitotoxic injury. Fundamental changes in all these areas have occurred in the time since most junior doctors currently gracing the middle rungs of the neurology training ladder last received any formal neuroscientific education as pre-clinical undergraduates up to 14 or 15 years ago. And for those of a scientific bent who have at least attempted to follow developments, the traditional lack of intercourse between basic neuroscientist and clinical neurologist, the geographical concentration of the former in a handful of universities, and the exacting requirements of clinical training posts have often combined to frustrate their curiosity. Study leave to attend expensive scientific symposia, which are neither intended nor structured to fulfil a primary educational role, is at best begrudged, often denied, and the tyro must resort to covert and furtive nocturnal incursions into Trends in Neurosciences. This perceived gap in postgraduate neurology training in the United Kingdom provided the background and justification for the recent Neuroscience for Clinicians meeting, organised by the CoEditor of this journal and funded generously and with great foresight by the Guarantors of Brain. Seventy neurologists mostly junior, some less obviously so, from Britain and continental Europe - were addressed and informed by 20 or more scientists of eminence representing a broad range of disciplines. The format was conservative - some might say reactionary: a smallish college room, no videos, no gimmicks, double projection available only to Fellows of the Royal Society (or does by memory mislead me?), a taxing 11 or 12 short lectures a day. But there was an air of informality - to paraphrase the host and organiser, many speakers exhibiting a fine disregard for their titles - which blended easily with the intimacy afforded by the surroundings and the manageable number of participants. Broad neuroscientific themes had been employed to harness related but disparate presenters; the tempting trap of arranging a stunning but random (and ultimately unsatisfying) display of intellectual fireworks was carefully avoided, and the overall pattern was of a coordinated and discriminating exposde of much that is good in neuroscience in Britain. The programme highlighted two areas, "systems" neuroscience and cellular neurobiology, which have not only witnessed remarkable advances in recent years, but which, moreover, have lately seen increasingly fruitful relationships with clinical neurology - in the former area, happily ending a near-divorce of several decades' duration, while in the latter, forming a new union which is likely to have exciting and dramatic future implications for the practice of neurology. "Systems neuroscience" underpinned the first day's talks, ordered to reflect a template for clinical neuroscience, progressing from molecules via mechanisms to disease. The Molecular Basis of Memory (John Rawlins, University of Oxford) was followed by an account of memory systems and models (Dr. Alan Baddeley, University of Cambridge), before the baton was handed on to one of the few clinicians to speak, Dr. John Hodges, University Lecturer in Neurology, Cambridge. Tripping lightly around the limbic system, Dr. Hodges used clinical illustrations of a variety of amnestic conditions to provide a rdsum6 of current thinking on the anatomy of memory and its disorders. Aspects of visual neuroscience and perception were described by Professor Zeki (University College, London), Professor Humphries (Department of Cognitive Psy-
298 chology, University of Birmingham), and Dr. John Marshall (Radcliffe Infirmary, Oxford), while the remainder of the day included mechanisms and therapy of hearing impairment (Dr. Moore, University of Cambridge); pain (Professor Wall, University College, London); mathematical paradigms of movement and its neural control (Dr. Wing, University of Cambridge); primate sensorimotor systems and their organisation (Dr. Roger Lemon, University of Cambridge); and current and future strategies for functional rehabilitation after neural damage (Professor Brindley, Institute of Psychiatry, London). The second day's theme was cellular neurobiology. James Fawcett (University of Cambridge) opened the proceedings with a review of regeneration in the central nervous system, followed by Professor Walsh (University of London) on the molecular basis of neural development and repair. Professor Martin Raft (University College, London) spoke on the fundamental importance of apoptotic cell death, and what prevents it. The potential - biological and medical - of neural (Steve Dunnett, University of Cambridge) and glial (Bill Blakemore, University of Cambridge) cell transplants was discussed, while Dr. Tim Cheek (University of Cambridge) spoke on signal transduction in the nervous system. Professor Richard Frackowiack filled an unexpected breach in the programme with a discussion of positron emission tomography and its role in functional imaging of brain order and disorder. Dr. Michael Sofroniew (University of Cambridge) summarised mechanisms of neuronal degeneration and injury, and the programme was completed with two lectures on clinical and molecular neurogenetics by Dr. Kay Davies (University of Oxford) and Professor Anita Harding (Institute of Neurology, London).
Was the meeting a success? It was abundantly clear that all who attended had enjoyed the proceedings but, more than this, felt they had left a little more educated - in Mark Twain's terms, a little less unwashed - than they had arrived. It is hard to imagine how otherwise its success might be judged. Of course, minor details might be alterable - a minority felt that one or two sessions might bear a more practical emphasis; other appealed for a little more leavening. But such alterations represent details: what is surprising (although perhaps it should not be) is that after one outing, the meeting appears to have become indispensible and reversion to the status quo unthinkable. Ramon y Cajal [2] once wrote "Grey matter abounds in countries with grey skies". Regardless of the veracity and wisdom of this particular observation, it is a truism that to possess grey matter is one thing, to use it quite another. Neuroscience for Clinicians has exposed and filled a significant and widening breach in the landscape of postgraduate neurological education in the Britain. Nell Scolding, Cambridge, UK
Reference 1. Fox T (1965) Purposes of medicine. Harveian oration, 1965. Reprinted in The Lancet (1965) I : 801 2. Ramon y Cajal (1920) Charlas de cafe. Translated by FH Garrison
