Time for Brain Medicine

We propose a novel encompassing approach to clinical training with respect to structure and function of the brain. Rather than training almost exclusively in a field that addresses only particular aspects of brain disease (Figure 1A-B), we propose a foundation of training across multiple facets of brain disease that erases the barrier between psychiatry and neurology (Figure 1C-D). Importantly, this approach does not undo the development of any specialty or field but rather builds upon this underlying foundation. We will compare and contrast this approach to the current paradigm, as shown in Figure 1.

A brief description of current residency curricula in neurology and psychiatry, by year, is provided here as a frame of reference for the proposed changes.

The following features are common to existing programs and the proposed program:

The proposed program would differ from existing programs in several ways.

The first 2 years will be used to build a foundation of competency involving many aspects of brain medicine and disease (Figure 2A). Brain medicine residents would become capable of diagnosing and managing common and acute neurological and psychiatric conditions through traditional inpatient rotations (Figure 2B). The last 2 years would prepare trainees for their discipline of choice through tracks. These tracks may be specific subspecialties, such as addiction medicine, epilepsy, movement disorders, or interventional psychiatry. These tracks may also be more generalized, such as general neurology or general psychiatry, or provide the novel ability to train broadly across all of brain medicine. Some specialties are beyond the scope of a 4-year training program, such as child psychiatry or neuromuscular medicine, and will require additional fellowship training, just as they do today. Other fellowships would still be required unless subspecialty boards accepted training from a track. Of course, employers could hire subspecialists from a track even if these individuals are not board eligible, just as employers can today. A sample schedule of what a 4-year brain medicine residency might look like is shown in Figure 2B.

Time in training is a precious commodity. In an era of reduced resident work hours, bloated electronic medical records, increasing regulatory requirements, and expanding medical knowledge and subspecialties, is it possible to train in two specialties without increasing the duration of training? Even our current single-specialty system grapples with attaining proficiency in the face of time limitations (20, 21). How, then, can one possibly become competent in two specialties in only 4 years? We contend that it can be done through reprioritization. The brain medicine concept is not an accelerated program for the most gifted, nor is it a shortcut. Current combined neurology and psychiatry programs (in which all of the authors trained) reduce the combined 8 years of training into 6 years through overlapping shared requirements and not duplicating the intern year. In the proposed brain medicine program, as illustrated in Figure 1, several months of general medicine in the first year are reallocated to brain medicine. Furthermore, once a senior-resident level of competency is attained, various rotations less critical to one’s chosen field are reallocated and dedicated toward one’s chosen subspecialty (Figure 1).

We concede that achieving expertise in all brain subspecialties in 4 years is not possible. We contend that because subspecialists are increasingly practicing only within their subspecialty, it is not necessary to spend precious months of training in less relevant subspecialties. Even now, there are more subspecialties than there are months to rotate through them. The trend toward subspecialization is a product of the incredible expansion of knowledge in this last frontier of neuroscience. As a result, a misguided goal to maintain a traditionally accepted ratio of individual knowledge to available knowledge in one’s specialty (as a metric of competence) established 80 years ago could arguably result in a 30-year program today. It is therefore an untenable position to strive for the same depth across the entire breadth without continuously increasing training duration. Rather, creative solutions to the already restrictive time limitations must be conceived and implemented (22).

In current practice, a stroke specialist typically does not manage patients with new seizure onset or read the electroencephalogram, but rather he or she consults the epileptologist. After years of practicing only within one’s subspecialty, those skills not actively in use will fade. With this inherent reality in mind, what should be the goal of training? Is it to be capable of fully managing every patient (which is not currently accomplished), or is it to develop expertise in one’s subspecialty while appropriately referring with awareness of urgent issues, initial work-up, and treatment? This is the level of competency expected of a senior resident, which is currently supposed to be accomplished after 2 years of training. Brain medicine, therefore, is a deliberate shift from trying to become expert in all subspecialties to gaining a senior-resident level of competence and familiarity across aspects of the brain, followed by focused training related to one’s subspecialty. Currently, decisions of subspecialty are typically made in the third year, which would fit within the time frame of the proposed brain medicine program (Figure 1).

We have focused on subspecialties to this point, but neurologists and psychiatrists who have a more general practice constitute many of those in the two fields and are critical to the public health mission. Brain medicine easily incorporates training programs that remain broad (Figure 1D) and can be favorably compared with current structures (Figure 1A) but with an additional foundation that covers aspects of the whole brain. In this sense, brain medicine training is broad: it is more akin to internal medicine training than the narrow subspecialty of behavioral neurology & neuropsychiatry, for which combined neurology and psychiatry training is often confused.

It is worth emphasizing that in only 3 years, our internal medicine colleagues develop the clinical competence to diagnose and treat disease across all other organ systems and are actually board eligible without any required fellowship training. Our internal medicine colleagues are well respected and competent. Similar to the situation with internal medicine, all current neurology and psychiatry subspecialties would be available through brain medicine. Both fields are already governed by the same board, the ABPN, and there is already substantial overlap in tested material. We can also look to other combined programs: internal medicine-pediatrics programs combine two 3-year specialties into a 4-year program. Adding only one extra year is achieved through substantial overlap. By contrast, combining fields that merely intersect, such as child neurology, leading to board eligibility in pediatrics and neurology, as well as triple-board programs, leading to board eligibility in pediatrics, psychiatry, and child psychiatry, are both 5-year programs. Both add only 1 year to the standard 4 years of neurology or psychiatry despite only intersecting knowledge and practice bases. This raises the question of whether psychiatry and neurology have enough overlap (a single-organ system) to be accomplished in 4 years through the proposed changes described herein or whether, like the combined programs above, an additional year will be necessary.

With our collective experience from combined neurology and psychiatry training, we believe that 4 years may be sufficient to accomplish our stated goals of training, with additional expertise still available through fellowships. However, this is merely our opinion. We are proposing an idea that must be tested before it can be considered for widespread implementation. Trials and testing may reveal that 5 years is needed to achieve competence in brain medicine. The important consideration is that both 4-year and 5-year programs are tested, with detailed outcomes of competency and feasibility being assessed. Only then can the optimal length of a curriculum never before attempted be known with any certainty.

Our field is changing and requires a fresh view. For example, fellowship training may expand to include modes of practice, similar to existing nonapproved neurohospitalist fellowships or interventional psychiatry fellowships (23–25). Brain medicine provides the flexibility to focus on the most relevant training (Figure 1) while coming to understand manifestations of the whole brain.

Physician-scientists are key to the advancement of our clinical practice. Many existing neurology and psychiatry programs allow up to 1 year of dedicated research time. Given the breadth and depth of clinical training in the brain medicine model, protected research time would not be feasible. How will physician-scientists receive the necessary research training in brain medicine? In most cases today, aspiring trainees will go on to do additional postdoctoral training or fellowships, even in situations with built-in protected time during residency. Additionally, some medical and surgical programs address a similar challenge with optional extensions of residency while building protected time into the residency. Specialty tracks also have potential to reduce clinical time in fellowships, leading to earlier independence. Ultimately, we who are physician-scientists contend that the benefit of clinical training across the brain sciences has outweighed the potential cost of postdoctoral research training.

Change is challenging. How can a change of this magnitude actually be implemented? The first–and arguably most important–point is that we are proposing a change in residency training but not in departmental structure or clinical practice models. In other words, while this training model allows for change in response to neuroscientific advances to improve patient care, the only direct change is in residency rotations. Leaving most of the current infrastructure intact is an advantage of the brain medicine training model and may help facilitate this experiment. None of the following would have to be changed: ACGME requirements, trainee competencies, ABPN board-certification examinations, existing clinics and services, faculty positions, promotion structures, and so forth. The difference comes not in what physicians practice but in how we practice and, ultimately, in how well we practice. As an example, if a patient is seeking a movement specialist, he or she will be referred to a movement specialist in a neurology department. The difference will be that this movement specialist would have a greater background in psychiatry from the first 2 years of training, with which to manage comorbid conditions and more keenly recommend medication changes if iatrogenic contributions are recognized. Additionally, this movement specialist would have had increased exposure to his or her chosen subspecialty before a fellowship (Figure 1). The individual would otherwise be hired and promoted exactly as he or she would in the current structure.

All of this being the case, changing a residency structure is not trivial. Multiple levels of stakeholders have vested interests in these programs and must be included in the process of actually implementing brain medicine: the ACGME and its Review and Recognition Committee over neurology and psychiatry; the ABPN as the governing board for both specialties; and governing entities of both specialties, which include the American Psychiatric Association, the Association of University Professors of Neurology, the American Academy of Neurology, and the American Neurological Association. Change is difficult, and change should not be made only for the sake of change. The benefits of a brain medicine training program must prove beneficial in smaller pilot programs before widespread support is solicited.

The ACGME has a platform for novel pilot residency programs (26). Thus, a stepwise integration “where the rubber meets the road” is possible and appropriate. We expect that the model would be tested before full-scale implementation. It would likely start with a resident from one program, then another, then perhaps a small cohort, then numerous cohorts, and so forth. As with all things, the idea must be tested, and if it proves to be superior and feasible, it will naturally emerge as the predominant training paradigm. As it is in science, a novel idea may begin with a single subject before larger studies are warranted and before eventual widespread acceptance, if merited. One such scientific example of this principle comes from one of the authors of the present article (M.S.G.) (27).

What if there are insufficient resources at a given program for combined training? Many smaller community programs may be able to build collaborative training models in the same way that categorical programs are started today. In cases where this is still not feasible, brain medicine programs need not exist at the exclusion of individual neurology or psychiatry programs alone. Similarly, while large academic programs typically have expertise in most or all subspecialties, smaller academic programs may not have sufficient exposure for all subspecialty tracks. Community-based residencies typically aim to train generalists, which still fits in the framework of brain medicine (Figure 1D). In short, the brain medicine model does not take away from our current training system, but rather it adds to it.