- Email: [email protected]
NEUROLOGICAL TRAINING IN THE U.S.A.
172
without their drugs. But many may still regain their independence if once they can be induced to come for and persevere with hospital treatriient. Without inpatient treatment the chances that any will reform are remote. Treatment, moreover, should not be thought of as ending with discharge. Vocational training is often essential and patients have to be supervised and encouraged to make new friends after their return to the outside world. Because of shortage of staff, however, this is often only an ideal. Meanwhile, of the many youngsters taking hemp or amphetamines, the more adventurous begin to experiment with heroin obtained from " registered " addicts. They become addicted themselves and introduce a fresh circle of acquaintance to the habit. The operation of this process is reflected in the official figures for opiate addiction in this country. These have risen sharply over the past few years and particularly among the young..! Of 14 female addicts admitted to the Spelthorne St. Mary Nursing Home in 1958, none was under twenty-five years of age; in 1961, 2 out of 16 were under twenty-five, and in 1964, 4.
Lancet, 1964, i,
649.
Medical Education NEUROLOGICAL TRAINING IN THE U.S.A.* R. A. HENSON Land., F.R.C.P.
M.D.
From The London
Hospital., London,
E.1
THIS investigation was carried out during a seven weeks’ stay in the U.S.A. and Canada in the autumn of 1964. The journey was made in the belief that the time is ripe for a reappraisal of neurological training in Great Britain. THE TRAINING OF NEUROLOGISTS
The American neurological training programme lasts three years. Requirements for admission differ, but in experience general medicine is usually demanded and in some centres two years are necessary. The pattern oF training varies substantially. In some centres great stress is placed on neuropathology, and residents may work at this subject for as long as a year, though they continue to do some clinical work during this time. At other schools there is a strong scientific orientation, which is reflected in the selection of candidates. In larger centres the policy is eclectic, and young men with a bent for clinical work and teaching receive excellent training alongside contemporaries with the inclination and capacity to be nurtured in the basic techniques of modern scientific research.
Heads of departments were generally satisfied with the standard of applicants for residencies. Although general medicine attracts the majority of able young men embarking on careers as physicians, there is an excess of good candidates at centres with high reputations. The quality of trainees was clearly high in these schools. The number of residents is much larger than in Britain, and the difference is greater than expected on the score of population. The smallest team encountered numbered six. In addition, residents in general medicine, pxdiatric neurology, neuro-ophthalmology, and psychiatry rotate through neurological departments, though arrangements differ from place to place. Some neurosurgeons like their *
version of Education.
Abridged
a
report
to
the Association for the
Study of Medical
8 out of 20. None had been first introduced to the drug in the course of therapy. The rise of drug addiction among the young is only part of a wide social phenomenon and research is needed into all its aspects. Its prevention is the more important because of the relatively poor results of treatment. There seems therefore to be a good case for tightening up the regulations governing the provision of narcotics for recognised addicts. This should, for example, become the prerogative of a few central clinics where each addict’s requirements would first be assessed; and for the addicts themselves formal registration should be com-
pulsory. SUMMARY
Young heroin and cocaine addicts were treated in hospital by group psychotherapy. The long-term results were disappointing. Relapse is the more probable because of the ease with which recognised addicts can lawfully obtain drugs from their doctor. The introduction of opiates into the community in this way leads to fresh addiction among young people. Stricter regulation of addicts’ supplies is suggested. residents to spend time in the neurological department. The content of the training programme is influenced by the form of the specialist board examination, which requires knowledge of clinical neurology, psychiatry,
neuropathology, pædiatric neurology, electroencephalography, and basic neurological sciences. The organisation of programmes varied substantially from place to place, but all aspects of the curriculum were fully covered in the centres visited. On the clinical side the thoroughness and care with which patients were prepared for presentation was impressive, and it was rare to find a physical sign or historical point which had been overlooked. There was always ample time for consideration of each patient’s case. Supervision was close in most centres, and approval of special investigations from a member of staff was generally required. In the outpatient clinics supervision was more intensive and thorough than is practicable in Great Britain. The large number of residents in training makes it possible to allocate individuals to certain main duties-for example, one man may work exclusively at consultations on other services for one or two months. In all places visited the neurological training was carried out within a general hospital, so that residents had access to a wide range of clinical material on other services. There has been a belief here that the British supervise juniors more closely than our American colleagues. In my experience the reverse is true. The most impressive feature of the clinical training was the time available for case presentation and discussion, and for consideration of ideas or questions posed by any member of the group. Every possible fact was wrung from each patient’s case, and every avenue of learning explored. No novel teaching methods or techniques were encountered; but an impressive range of group activities in all aspects of clinical and scientific neurology, general medicine, and other subjects was open to residents. Excellent courses in the basic neurological sciences are available in the larger schools, and the standard of lectures is high. In smaller schools residents may attend the lectures in neuroanatomy and neurophysiology which form part of the course for medical students. Altogether, the American neurological resident is fortunate in his opportunities to obtain a thorough grounding in the basic
173 I A few colleagues expressed theof a rewarding professional career; if he falls short of the view that residents lack general supervision, or moralrequired academic standards, the price of failure is : successful private practice. There are several tutoring, and there may be some truth in this criticism; financially but at least one head of department appoints regular categories of practice-for example, full-time academic times for such supervision. appointments, with or without restricted, personally are residents to Although neurological required undergo remunerative, private practice; geographic whole-time some training in psychiatry, there was no unanimiry on consultants; physicians with rooms outside the hospital the value or necessity of such training. The formal bonds but assisting on the wards and in the outpatient clinics; which link the two subjects are stronger than in Britain- other physicians working outside the hospital but attendthe same specialist board devises the examinations for ing the outpatient clincs; and physicians entirely engaged neurologists and psychiatrists-but American neurologists in private practice. In the larger centres teaching responsiencountered generally regarded internal medicine as bilities are being increasingly transferred to men in their true associate. The predominance of psycho- full-time academic appointments. Staffs are very much and in American psychiatry poses larger than in Britain, and the clinical load is much theory practice analytic substantial problems in identification. In schools with a lighter. The great emphasis placed on research in the U.S.A. is large acute psychiatric inpatient department the period of was Neuroas valuable. well known. Exceptional clinical and teaching skills are regarded psychiatric experience surgical experience is not expected. generally insufficient to obtain their possessors the senior Successful After completing his residency, or training-time, the appointments in well-known departments. candidates are of out and has two to further in capable carrying usually superneurologist spend young years basic research. These are before he sit board’s his vising requirements perfectly gaining experience may specialist examination. This time may be passed in military service, reasonable, for the appointments are to university departacademic posts, including research, or private practice. ments. Some Americans expressed the opinion that the Travel to another country is permissible at this stage if emphasis placed on research produces too theoretical a specifically prescribed by the trainee’s supervisor; other- training programme, for the majority of residents are still destined for a clinical career; there may be seme truth wise no credit is allowed for time spent abroad. The only exception to this rule is the grant of one year’s experience in this criticism, but the clinical teaching was well done at Heads of departments appeared credit which may be permitted for time spent at the the centres visited. National Hospital, Queen Square, London. One year of concerned to ensure that their staffs included able clinical credit for training in neurology is also allowed if a specific teachers. The vast sumsavailable for research make it unlikely that any worth-while project goes unsupported. post is held at Queen Squared On the other hand, this prodigal expenditure enables THE SPECIALIST BOARD EXAMINATION pedestrian schemes to be financed. There can be no The board examination in neurology and psychiatry is objection to this policy in a rich country so long as held twice yearly. At present the examination is entirely the Government and people choose to spend money clinical and oral, occupying some eight hours in one day. thus, always assuming that clinical instruction does not The examination was discussed with junior and senior suffer. examiners, and with successful and unsuccessful candiQuestions of temperament, social attitudes, and dates. The candidates were united in their satisfaction philosophy demand brief notice. American clinicians are with the fairness and scope of the examination. When a extremely forbearing towards their students and patients. candidate failed he was made aware of the reasons for his The active part some patients took in their consultations failure, and this provided some solace. The examination was a source of mild surprise. This probably stems from is regarded as a test of the candidates’ adequacy and the forbearance of doctors in dealing with patients against reliability in their chosen field, and the pass-rate is high the background of an egalitarian and informed society. by British standards for comparable diplomas. As a whole, Americans seemed genuinely committed to building a better society. Furthermore, they are an THE AMERICAN NEUROLOGICAL SCENE The energetic, industrious, and gregarious people. It was not part of my brief to dissect or criticise colleagues visited worked long hours by British standards, American methods of training or practice. There was so some labouring for most of the weekend and long into much to admire, and to enthuse, that it is preferable to the night. Whilst this phenomenon sometimes represents concentrate on these features. (American colleagues complete commitments to medicine, it is partially attributshowed no sense of satisfaction with things as they are; able to the number of group activities. Clinical and basic indeed, there was a general desire for improvement and research occupy more time than in comparable British expansion.) Nevertheless, the pattern of practice, social institutions. Certainly, the long hours worked are no attitudes, and temperament differ so greatly between the reflection of the clinical load. Lastly, the U.S.A. is a U.S.A. and Britain that these differences must be young man’s country. Promotion, responsibility, and explored before any attempt is made to discuss the ways financial success come earlier than in Britain. It is well in which our methods of training and practice can be known that the financial position of American schools is improved in the light of this investigation. Croesian by our standards; and the accommodation and The U.S.A. is still a land of opportunity. Within the equipment possessed by American colleagues furnish a next year new medical schools will provide vacancies for constant source of admiration and envy. between forty and fifty academic neurologists. Many APPLICATION OF AMERICAN METHODS IN BRITAIN existing centres require additional staff, and the field of private practice remains wide open. Theyoung Geographical, numerical, and financial considerations American neurologist of average competence is assured preclude any wholesale advocacy of American training methods in Britain. One American service in a large 1. Rupp, C. Neurology, 1964, 14, 1157.
neurological sciences.
174 as the New York Neurological Institute or Harvard units in Boston, may contain as many neurologists in training as all the centres in Britain combined. Under such conditions it is much easier to organise a uniform, comprehensive training scheme, and to arrange thorough coverage of basic neurological sciences with the assistance of the many experts who work in these departments. On the practical side, it must be admitted that many physicians in this country have an innate dislike of formal training programmes, and prefer a more elastic policy. Whilst American training schedules vary from school to school, there are certain requirements which every would-be neurologist knows he must fulfil. This system is fair, and there is much to be said for the introduction of a similar scheme here; however, the small number of British trainees would make a stereotyped programme difficult to arrange except on a national basis, and this is a field which remains unexplored. Meanwhile the recent proposals of the Royal College of Physicians on the training of neurologists set up an adequate framework within which programmes can be
school, such
the
two
organised. At the present time the British training system is geared the production of competent clinical neurologists. Americans were frank in their criticism of British neurological research, but none questioned the standard of our clinical practice nor the adequacy of our clinical training methods. Indeed, the reputation of our clinical work stands high, and British neurologists are welcomed in the U.S.A. This is hardly sufficient, however, in the twentieth century; there is an obvious need to develop and enlarge the academic side of British neurology. It is no longer sufficient to offer excellent clinical training In this context a distinguished programmes alone. Indian neurglogist recently remarked that he thought he and his colleagues could now provide full clinical training facilities; their young men needed training in the basic sciences and in modern techniques of investigation, and he felt inclined to send them to America for such training. There are many expert clinical neurologists throughout the British Commonwealth, and they may be expected ultimately to subscribe to the Indian view. The fact that many of these physicians acquired their skill in this country is beside the point. The setting up of three professorial units and more liberal support from the Medical Research Council have already gone some way towards meeting the foregoing types of criticism, but the reputation of British neurology for research has been tarnished in recent years, and its re-establishment will take time and effort. to
The best American training excels the British in opportunities for research, exposure to basic neuroBetter logical sciences, and individual supervision. of residents is the fruit of large staffs, but oversight national attitudes also play an important part. The amount of supervision in Britain obviously depends on the individual consultant, although the most enthusiastic person is limited by his own conditions of employment. It is common experience to work in an outpatient clinic and try to fulfil three functions-namely, to provide a consultant service, teach medical students, and supervise junior staff. This is a formidable task which constantly challenges neurologists in British teaching hospitals. No official time is available for regular periods of instruction or personal supervision. The small number of neurologists in training makes exposure to basic neurological
sciences difficult to arrange. There is rarely time for a registrar to attend the appropriate courses in the local medical school. Substantial improvement in British neurological training can only be achieved by reforms in the whole field of neurological practice. At present, academic clinical neurology is represented by three professorial departments and a few appointments on medical units. Practice, teaching, and clinical research lie largely in the hands of part-time physicians, who are remunerated according to the amount of patient care they undertake. These men commonly have inadequate departmental accommodation and assistance for routine work or research. There is need for more academic posts and geographic whole-time appointments. Improved physical working conditions with appropriate technical and secretarial help are also required. Concentration of regional neurological services and more direct linkages with teaching hospitals form a further profitable line of development. As things stand, the British teaching-hospital neurologist can offer his trainees a wide range of clinical experience, and the benefit of his personal clinical expertise. There are several ways in which improvements can be made now:
(1) It is essential for each trainee to have a consultant individually responsible for planning and overseeing his programme and progress. The consultant should act
as technical and moral tutor, and meet his charge regularly for private discussion. No doubt some consultants do this already. (2) The allocation of clinical and undergraduate teaching duties is too rigid in Britain. Teaching hospitals generally have at least two neurologists. It should not be difficult to redispose routine work so that one member of staff is alternately freed for supervision of research and teaching and clinical activities. (3) Group learning sessions are widely employed in larger centres, and their extension should be encouraged by official recognition that these are periods of work, not entertainment. (4) Instruction of registrars with an aptitude for basic research techniques poses more difficult problems. It is rarely possible to allow the trainee more than one laboratory day each week. However, colleagues working in the basic sciences are generally willing to help a young, enthusiastic clinician on this basis. Once the trainee has equipped himself in some aspect of laboratory work there should be no difficulty in arranging for him to spend a full year in research, either in Britain or abroad. (5) Registrars working in London have a wide range of lectures in basic neurological sciences which they may attend, provided their hospital duties allow them so to do. There is room for a regular course in these subjects, which would be open to all neurological trainees throughout the country. Such a course could well be organised by the Institute of Neurology, and take place annually or biannually as required. There should be facilities for teaching the fundamentals of neuropathology, neuroradiology, and electrophysiology at every medical school with an establishment for a senior registrar in neurology. The course suggested would deal with the more advanced aspects of these subjects and with neuroanatomy, neurophysiology, ,
neurochemistry, genetics, and .neurobiology. It is hoped that academic expansion and increased staffing will soon enable more radical improvements to be made. Meanwhile, there is time for further thought on the content and organisation of neurological training. This work
carried out during tenure of a Commonwealth the nomination of the Association for the Study of Medical Educatiork. My thanks are due to the many American colleagues and residents who assisted my inquiries.
fellowship,
on
was
without their drugs. But many may still regain their independence if once they can be induced to come for and persevere with hospital treatriient. Without inpatient treatment the chances that any will reform are remote. Treatment, moreover, should not be thought of as ending with discharge. Vocational training is often essential and patients have to be supervised and encouraged to make new friends after their return to the outside world. Because of shortage of staff, however, this is often only an ideal. Meanwhile, of the many youngsters taking hemp or amphetamines, the more adventurous begin to experiment with heroin obtained from " registered " addicts. They become addicted themselves and introduce a fresh circle of acquaintance to the habit. The operation of this process is reflected in the official figures for opiate addiction in this country. These have risen sharply over the past few years and particularly among the young..! Of 14 female addicts admitted to the Spelthorne St. Mary Nursing Home in 1958, none was under twenty-five years of age; in 1961, 2 out of 16 were under twenty-five, and in 1964, 4.
Lancet, 1964, i,
649.
Medical Education NEUROLOGICAL TRAINING IN THE U.S.A.* R. A. HENSON Land., F.R.C.P.
M.D.
From The London
Hospital., London,
E.1
THIS investigation was carried out during a seven weeks’ stay in the U.S.A. and Canada in the autumn of 1964. The journey was made in the belief that the time is ripe for a reappraisal of neurological training in Great Britain. THE TRAINING OF NEUROLOGISTS
The American neurological training programme lasts three years. Requirements for admission differ, but in experience general medicine is usually demanded and in some centres two years are necessary. The pattern oF training varies substantially. In some centres great stress is placed on neuropathology, and residents may work at this subject for as long as a year, though they continue to do some clinical work during this time. At other schools there is a strong scientific orientation, which is reflected in the selection of candidates. In larger centres the policy is eclectic, and young men with a bent for clinical work and teaching receive excellent training alongside contemporaries with the inclination and capacity to be nurtured in the basic techniques of modern scientific research.
Heads of departments were generally satisfied with the standard of applicants for residencies. Although general medicine attracts the majority of able young men embarking on careers as physicians, there is an excess of good candidates at centres with high reputations. The quality of trainees was clearly high in these schools. The number of residents is much larger than in Britain, and the difference is greater than expected on the score of population. The smallest team encountered numbered six. In addition, residents in general medicine, pxdiatric neurology, neuro-ophthalmology, and psychiatry rotate through neurological departments, though arrangements differ from place to place. Some neurosurgeons like their *
version of Education.
Abridged
a
report
to
the Association for the
Study of Medical
8 out of 20. None had been first introduced to the drug in the course of therapy. The rise of drug addiction among the young is only part of a wide social phenomenon and research is needed into all its aspects. Its prevention is the more important because of the relatively poor results of treatment. There seems therefore to be a good case for tightening up the regulations governing the provision of narcotics for recognised addicts. This should, for example, become the prerogative of a few central clinics where each addict’s requirements would first be assessed; and for the addicts themselves formal registration should be com-
pulsory. SUMMARY
Young heroin and cocaine addicts were treated in hospital by group psychotherapy. The long-term results were disappointing. Relapse is the more probable because of the ease with which recognised addicts can lawfully obtain drugs from their doctor. The introduction of opiates into the community in this way leads to fresh addiction among young people. Stricter regulation of addicts’ supplies is suggested. residents to spend time in the neurological department. The content of the training programme is influenced by the form of the specialist board examination, which requires knowledge of clinical neurology, psychiatry,
neuropathology, pædiatric neurology, electroencephalography, and basic neurological sciences. The organisation of programmes varied substantially from place to place, but all aspects of the curriculum were fully covered in the centres visited. On the clinical side the thoroughness and care with which patients were prepared for presentation was impressive, and it was rare to find a physical sign or historical point which had been overlooked. There was always ample time for consideration of each patient’s case. Supervision was close in most centres, and approval of special investigations from a member of staff was generally required. In the outpatient clinics supervision was more intensive and thorough than is practicable in Great Britain. The large number of residents in training makes it possible to allocate individuals to certain main duties-for example, one man may work exclusively at consultations on other services for one or two months. In all places visited the neurological training was carried out within a general hospital, so that residents had access to a wide range of clinical material on other services. There has been a belief here that the British supervise juniors more closely than our American colleagues. In my experience the reverse is true. The most impressive feature of the clinical training was the time available for case presentation and discussion, and for consideration of ideas or questions posed by any member of the group. Every possible fact was wrung from each patient’s case, and every avenue of learning explored. No novel teaching methods or techniques were encountered; but an impressive range of group activities in all aspects of clinical and scientific neurology, general medicine, and other subjects was open to residents. Excellent courses in the basic neurological sciences are available in the larger schools, and the standard of lectures is high. In smaller schools residents may attend the lectures in neuroanatomy and neurophysiology which form part of the course for medical students. Altogether, the American neurological resident is fortunate in his opportunities to obtain a thorough grounding in the basic
173 I A few colleagues expressed theof a rewarding professional career; if he falls short of the view that residents lack general supervision, or moralrequired academic standards, the price of failure is : successful private practice. There are several tutoring, and there may be some truth in this criticism; financially but at least one head of department appoints regular categories of practice-for example, full-time academic times for such supervision. appointments, with or without restricted, personally are residents to Although neurological required undergo remunerative, private practice; geographic whole-time some training in psychiatry, there was no unanimiry on consultants; physicians with rooms outside the hospital the value or necessity of such training. The formal bonds but assisting on the wards and in the outpatient clinics; which link the two subjects are stronger than in Britain- other physicians working outside the hospital but attendthe same specialist board devises the examinations for ing the outpatient clincs; and physicians entirely engaged neurologists and psychiatrists-but American neurologists in private practice. In the larger centres teaching responsiencountered generally regarded internal medicine as bilities are being increasingly transferred to men in their true associate. The predominance of psycho- full-time academic appointments. Staffs are very much and in American psychiatry poses larger than in Britain, and the clinical load is much theory practice analytic substantial problems in identification. In schools with a lighter. The great emphasis placed on research in the U.S.A. is large acute psychiatric inpatient department the period of was Neuroas valuable. well known. Exceptional clinical and teaching skills are regarded psychiatric experience surgical experience is not expected. generally insufficient to obtain their possessors the senior Successful After completing his residency, or training-time, the appointments in well-known departments. candidates are of out and has two to further in capable carrying usually superneurologist spend young years basic research. These are before he sit board’s his vising requirements perfectly gaining experience may specialist examination. This time may be passed in military service, reasonable, for the appointments are to university departacademic posts, including research, or private practice. ments. Some Americans expressed the opinion that the Travel to another country is permissible at this stage if emphasis placed on research produces too theoretical a specifically prescribed by the trainee’s supervisor; other- training programme, for the majority of residents are still destined for a clinical career; there may be seme truth wise no credit is allowed for time spent abroad. The only exception to this rule is the grant of one year’s experience in this criticism, but the clinical teaching was well done at Heads of departments appeared credit which may be permitted for time spent at the the centres visited. National Hospital, Queen Square, London. One year of concerned to ensure that their staffs included able clinical credit for training in neurology is also allowed if a specific teachers. The vast sumsavailable for research make it unlikely that any worth-while project goes unsupported. post is held at Queen Squared On the other hand, this prodigal expenditure enables THE SPECIALIST BOARD EXAMINATION pedestrian schemes to be financed. There can be no The board examination in neurology and psychiatry is objection to this policy in a rich country so long as held twice yearly. At present the examination is entirely the Government and people choose to spend money clinical and oral, occupying some eight hours in one day. thus, always assuming that clinical instruction does not The examination was discussed with junior and senior suffer. examiners, and with successful and unsuccessful candiQuestions of temperament, social attitudes, and dates. The candidates were united in their satisfaction philosophy demand brief notice. American clinicians are with the fairness and scope of the examination. When a extremely forbearing towards their students and patients. candidate failed he was made aware of the reasons for his The active part some patients took in their consultations failure, and this provided some solace. The examination was a source of mild surprise. This probably stems from is regarded as a test of the candidates’ adequacy and the forbearance of doctors in dealing with patients against reliability in their chosen field, and the pass-rate is high the background of an egalitarian and informed society. by British standards for comparable diplomas. As a whole, Americans seemed genuinely committed to building a better society. Furthermore, they are an THE AMERICAN NEUROLOGICAL SCENE The energetic, industrious, and gregarious people. It was not part of my brief to dissect or criticise colleagues visited worked long hours by British standards, American methods of training or practice. There was so some labouring for most of the weekend and long into much to admire, and to enthuse, that it is preferable to the night. Whilst this phenomenon sometimes represents concentrate on these features. (American colleagues complete commitments to medicine, it is partially attributshowed no sense of satisfaction with things as they are; able to the number of group activities. Clinical and basic indeed, there was a general desire for improvement and research occupy more time than in comparable British expansion.) Nevertheless, the pattern of practice, social institutions. Certainly, the long hours worked are no attitudes, and temperament differ so greatly between the reflection of the clinical load. Lastly, the U.S.A. is a U.S.A. and Britain that these differences must be young man’s country. Promotion, responsibility, and explored before any attempt is made to discuss the ways financial success come earlier than in Britain. It is well in which our methods of training and practice can be known that the financial position of American schools is improved in the light of this investigation. Croesian by our standards; and the accommodation and The U.S.A. is still a land of opportunity. Within the equipment possessed by American colleagues furnish a next year new medical schools will provide vacancies for constant source of admiration and envy. between forty and fifty academic neurologists. Many APPLICATION OF AMERICAN METHODS IN BRITAIN existing centres require additional staff, and the field of private practice remains wide open. Theyoung Geographical, numerical, and financial considerations American neurologist of average competence is assured preclude any wholesale advocacy of American training methods in Britain. One American service in a large 1. Rupp, C. Neurology, 1964, 14, 1157.
neurological sciences.
174 as the New York Neurological Institute or Harvard units in Boston, may contain as many neurologists in training as all the centres in Britain combined. Under such conditions it is much easier to organise a uniform, comprehensive training scheme, and to arrange thorough coverage of basic neurological sciences with the assistance of the many experts who work in these departments. On the practical side, it must be admitted that many physicians in this country have an innate dislike of formal training programmes, and prefer a more elastic policy. Whilst American training schedules vary from school to school, there are certain requirements which every would-be neurologist knows he must fulfil. This system is fair, and there is much to be said for the introduction of a similar scheme here; however, the small number of British trainees would make a stereotyped programme difficult to arrange except on a national basis, and this is a field which remains unexplored. Meanwhile the recent proposals of the Royal College of Physicians on the training of neurologists set up an adequate framework within which programmes can be
school, such
the
two
organised. At the present time the British training system is geared the production of competent clinical neurologists. Americans were frank in their criticism of British neurological research, but none questioned the standard of our clinical practice nor the adequacy of our clinical training methods. Indeed, the reputation of our clinical work stands high, and British neurologists are welcomed in the U.S.A. This is hardly sufficient, however, in the twentieth century; there is an obvious need to develop and enlarge the academic side of British neurology. It is no longer sufficient to offer excellent clinical training In this context a distinguished programmes alone. Indian neurglogist recently remarked that he thought he and his colleagues could now provide full clinical training facilities; their young men needed training in the basic sciences and in modern techniques of investigation, and he felt inclined to send them to America for such training. There are many expert clinical neurologists throughout the British Commonwealth, and they may be expected ultimately to subscribe to the Indian view. The fact that many of these physicians acquired their skill in this country is beside the point. The setting up of three professorial units and more liberal support from the Medical Research Council have already gone some way towards meeting the foregoing types of criticism, but the reputation of British neurology for research has been tarnished in recent years, and its re-establishment will take time and effort. to
The best American training excels the British in opportunities for research, exposure to basic neuroBetter logical sciences, and individual supervision. of residents is the fruit of large staffs, but oversight national attitudes also play an important part. The amount of supervision in Britain obviously depends on the individual consultant, although the most enthusiastic person is limited by his own conditions of employment. It is common experience to work in an outpatient clinic and try to fulfil three functions-namely, to provide a consultant service, teach medical students, and supervise junior staff. This is a formidable task which constantly challenges neurologists in British teaching hospitals. No official time is available for regular periods of instruction or personal supervision. The small number of neurologists in training makes exposure to basic neurological
sciences difficult to arrange. There is rarely time for a registrar to attend the appropriate courses in the local medical school. Substantial improvement in British neurological training can only be achieved by reforms in the whole field of neurological practice. At present, academic clinical neurology is represented by three professorial departments and a few appointments on medical units. Practice, teaching, and clinical research lie largely in the hands of part-time physicians, who are remunerated according to the amount of patient care they undertake. These men commonly have inadequate departmental accommodation and assistance for routine work or research. There is need for more academic posts and geographic whole-time appointments. Improved physical working conditions with appropriate technical and secretarial help are also required. Concentration of regional neurological services and more direct linkages with teaching hospitals form a further profitable line of development. As things stand, the British teaching-hospital neurologist can offer his trainees a wide range of clinical experience, and the benefit of his personal clinical expertise. There are several ways in which improvements can be made now:
(1) It is essential for each trainee to have a consultant individually responsible for planning and overseeing his programme and progress. The consultant should act
as technical and moral tutor, and meet his charge regularly for private discussion. No doubt some consultants do this already. (2) The allocation of clinical and undergraduate teaching duties is too rigid in Britain. Teaching hospitals generally have at least two neurologists. It should not be difficult to redispose routine work so that one member of staff is alternately freed for supervision of research and teaching and clinical activities. (3) Group learning sessions are widely employed in larger centres, and their extension should be encouraged by official recognition that these are periods of work, not entertainment. (4) Instruction of registrars with an aptitude for basic research techniques poses more difficult problems. It is rarely possible to allow the trainee more than one laboratory day each week. However, colleagues working in the basic sciences are generally willing to help a young, enthusiastic clinician on this basis. Once the trainee has equipped himself in some aspect of laboratory work there should be no difficulty in arranging for him to spend a full year in research, either in Britain or abroad. (5) Registrars working in London have a wide range of lectures in basic neurological sciences which they may attend, provided their hospital duties allow them so to do. There is room for a regular course in these subjects, which would be open to all neurological trainees throughout the country. Such a course could well be organised by the Institute of Neurology, and take place annually or biannually as required. There should be facilities for teaching the fundamentals of neuropathology, neuroradiology, and electrophysiology at every medical school with an establishment for a senior registrar in neurology. The course suggested would deal with the more advanced aspects of these subjects and with neuroanatomy, neurophysiology, ,
neurochemistry, genetics, and .neurobiology. It is hoped that academic expansion and increased staffing will soon enable more radical improvements to be made. Meanwhile, there is time for further thought on the content and organisation of neurological training. This work
carried out during tenure of a Commonwealth the nomination of the Association for the Study of Medical Educatiork. My thanks are due to the many American colleagues and residents who assisted my inquiries.
fellowship,
on
was