A career in neurologyBMJ 2004; 329 doi: https://doi.org/10.1136/bmj.329.7465.s93-a (Published 04 September 2004) Cite this as: BMJ 2004;329:s93
- Trevor Pickersgill, consultant neurologist
There is a shortage of neurologists in the United Kingdom. So now may be a good time to consider a career which combines clinical acumen, communication skills, and technology, say Owen Pearson, Savvas Hadjikoutis, and Trevor Pickersgill
Neurology is often seen as a difficult specialty populated by dry academics. This is a complete myth. It is a specialty that combines clinical acumen, communication skills, and technology—but a mildly obsessive personality trait may be helpful.
Range of conditions
Neurology is the branch of medicine that deals with disorders of the nervous system, including the brain, spinal cord, peripheral nerves, and muscles. They might be disorders that can be managed almost entirely in the community (such as epilepsy and migraine), be acute neurological emergencies (such as stroke, meningitis, encephalitis, or Guillain-Barré syndrome), or be chronic disabling conditions (such as multiple sclerosis and Parkinson's disease), where multidisciplinary care is essential.
Most patients with neurological symptoms present initially to primary care services. About one in eight of all general practitioner consultations are for neurological symptoms, and approximately 20% of acute medical admissions are for a neurological problem. About 20 000 people in every million of the population have a disability, often severe and progressive, as a result of neurological conditions. Changes in the age structure of the UK population will lead to increasing numbers of people with degenerative conditions of the brain such as dementia and Parkinson's disease. This, along with the introduction of new treatments, will increase the number of patients requiring accurate diagnosis, coordination of long term multidisciplinary management, and perhaps rationing of treatments.
More neurologists needed
More neurologists are needed in the United Kingdom. Currently, there are only about 350 whole time equivalent consultant neurologists, with a neurologist to patient ratio of 1:170 000 in the UK population, which compares unfavourably with most other European countries. There is considerable geographical variation in the ease of access to neurological services. Waiting times for outpatient appointments remain unacceptably long (over 20 weeks) in many areas of the United Kingdom and are as high as 20 months in Wales. Secondary waiting times for investigations such as brain imaging and clinical neurophysiology are often longer (in some areas over 52 weeks).
Most neurologists would like to be more concerned with acute neurology—reviewing and managing all acute patients with neurological problems—but with fewer than one neurologist on average in most acute hospitals, this reality is a long way off.⇓
Training—past and present
Applicants for higher medical training in neurology should have done at least two years' general professional training in approved posts and have obtained membership of the Royal College of Physicians (MRCP (UK) or (I)). General professional training is defined as a minimum of two years in approved posts with direct involvement in patient care and offering a wide range of experience in a variety of specialties. Eighteen months of the two years must be spent in posts providing experience in the admission and early follow up of acute emergencies. Not more than six months of the obligatory two years may be spent in the neurosciences. A period of experience in neurology at senior house officer (SHO) grade is considered desirable before entry to higher medical training, although it is not usually essential. Other valuable experience in the SHO grade would be psychiatry, neurosurgery, or ophthalmology. Non-UK graduates without the MRCP who compete for higher medical training posts must provide evidence of appropriate knowledge, training, and experience, particularly in the care of acute medical conditions.
Entry into the specialist registrar grade in neurology is highly competitive. Many applicants have postgraduate qualifications (such as an MD or PhD), publications, presentations to learned societies, and experience as a locum registrar in neurology. A large number of research fellows in the neurosciences are without a national training number. Prospective neurology trainees who are considering a period in research before competing for a national training number may find useful guidelines on appropriate research projects or posts on the Association of British Neurologists' website (see further information box).
Higher specialist training
The duration of higher medical training in neurology is five years. On enrolment with the Joint Committee on Higher Medical Training (JCHMT)—see further information box—and payment of the necessary fees, the trainee will receive a copy of the handbook, the curriculum for higher medical training in neurology, and a training record. In common with all other JCHMT specialties, the trainee needs to keep a written record of training, to be countersigned by the relevant trainer every year. Each year trainees will be required to undergo formal review—the record of in-training assessment (RITA)—by a panel consisting of representatives of the postgraduate dean's office and the regional specialty training committees, where progress in the year will be recorded. Trainees in year 3/4 will need to undergo the penultimate year assessment in common with all other JCHMT specialty trainees, which requires a more thorough assessment of training done and training still required before the certificate of the completion of specialist training (CCST) can be issued. This is usually done in conjunction with an assessing neurologist from another deanery.
By the end of the five year period the trainee must have obtained experience in clinical neurophysiology, rehabilitation medicine, neurosurgery, intensive care, neuroimaging, head injury, and clinical audit. In addition, the trainee is encouraged to obtain experience in stroke medicine, neuroophthalmology, neuro-otology, neuropaediatrics, pain management, spinal injury, neuropathology, neurogenetics, neuroimmunology, neuropsychology, neuropsychiatry, and uroneurology.
In the final two years of training the trainee may be encouraged to develop a special interest in one of the subspecialties if he or she wishes. In some deaneries arrangements for regular day release to gain clinical experience at national centres of excellence are encouraged, although trainees will need to apply for travel grants from educational or drug company sources.
Pros and cons of a career in neurology
Remains clinically orientated
Exposure to fascinating conditions
Variety of clinical disorders
New treatments constantly being developed
Many research opportunities
Retention of links with academic centres
Many district general hospitals want more neurology input
No exams after MRCP—yet
Well structured training programmes
Low intensity of on-call work, although this may change
Long waiting times
Large number of untreatable or poorly treated disorders
Research now almost a prerequisite for entry into training
Often under resourced
Rationing of new, expensive treatments
Research experience is encouraged (almost expected) and can count for up to a year towards the CCST. Ideally, it should be relevant to neurology and undertaken in a department where the trainee has some clinical commitment—for example, one general neurology clinic a week and participation in the registrar on-call rota. Some trainees may want to spend two or three years in research either before entering higher medical training or by taking out-of-programme experience after entering a programme.
Some trainees may seek dual CCSTs, commonly with clinical neurophysiology or rehabilitation. Dual certification can be achieved in six and a half years for neurology and clinical neurophysiology and seven years for neurology and rehabilitation medicine.
After satisfactory completion of a training programme, the trainee will be able to apply for his or her CCST. Employment in the specialist registrar grade will normally continue for six months after completion of training in order to give time for application and appointment to a consultant post.
The United Kingdom has too few consultant neurologists. In the past seven years the Association of British Neurologists has produced three documents on the provision of services for adult neurological patients. In 19961 and 19972 the association concluded that comprehensive care at regional centres and more focused care in local hospitals would require at least one consultant neurologist per 100 000 population. The third document, in 2002,3 addressed the care of inpatients with acute neurological illnesses in local hospitals. It emphasised the importance and clinical benefits of all such patients being under the care of a consultant neurologist. This comprehensive care would need one consultant neurologist per 40 000 population.
To meet this target the numbers of consultant posts are being increased and are more likely to be available in district general hospitals (with some sessions in the regional neurology centre—the managed clinical network model) or teaching or university hospitals—usually neurology and neurosurgery units with associated regional tertiary services. Opportunities for pure academic posts are available.4
Most neurologists maintain a subspecialty interest, often stemming from their days in training or research, and provide a regional expert service for particular diseases or disease groupings—for example, neuroinflammatory disease, muscle disease, peripheral neuropathy and epilepsy.
With the Modernising Medical Careers initiative the shape of neurology training may change dramatically.5 The education and training subcommittee of the Association of British Neurologists is actively engaged in talks with other specialty associations, the relevant royal colleges, and the Department of Health to promote the idea of a generic neuroscience specialty training programme. Trainees would compete for entry into neuroscience specialty training after completion of their foundation programme and enter a phase of basic neuroscience training. The aim would be to become competent in a range of stem neuroscience disciplines, possibly to include neurology, neurosurgery, psychiatry, ophthalmology, rehabilitation medicine, and allied areas. Trainees would then, through gaining both generic (common across a number of specialty areas) and specialty specific educational credits, be able to progress seamlessly into higher training in one of the specialties leading ultimately to the new certificate of completion of training.
Go to web extra at bmjcareers.com/careerfocus and references for Further information