Neurology Education in 2035

Abstract

In the past decade, there have been dramatic changes in all aspects of neurologic care, and along with this, neurology education has transformed. These changes have affected all aspects of education across the educational continuum, including learners, teachers, educators, content, delivery methods, assessments, and outcomes. Health systems science, health humanities, diversity, equity, and inclusion and health disparities are becoming core components of neurology curricula, and, in the future, will be integrated into every aspect of our educational mission. The ways in which material is taught and learned have been influenced by technologic innovations and a growing understanding of the science of learning. We forecast that this trend will continue, with learners choosing from an array of electronic resources to engage with fundamental topics, allowing front-line clinical teachers to spend more time supporting critical reasoning and teaching students how to learn. There has been a growing differentiation of educational roles (i.e., teachers, educators, and scholars). We forecast that these roles will become more distinct, each with an individualized pattern of support and expectations. Assessment has become more aligned with the work of the learners, and there are growing calls to focus more on the impact of educational programs on patient care. We forecast that there will be an increased emphasis on educational outcomes and public accountability for training programs. In this article, we reflect on the history of medical education in neurology and explore the current state to forecast the future of neurology education and discuss ways in which we can prepare.

Almost everyone involved in the supervision of house staff has been asked to complete a credentialing form at some point; residency and fellowship directors often complete many of these forms every week. These forms ask whether the director recommends the clinician as a member of the medical team. Some forms even include a version of the following question: “would you recommend this person to provide medical care for a member of your family?” While our pen (or cursor) hovers over this checkbox, there is an opportunity for us to reflect on the importance of our educational mission. Every element of our educational programming feeds into this small but extraordinarily meaningful action. As we discuss potential changes in neurology education over the next decade or so, we hope to maintain the focus on the end product of our educational journey: a workforce of neurologic clinicians who can provide the best care for all our loved ones.

“The End of History”

“The philosophies of one age have become the absurdities of the next, and the foolishness of yesterday has become the wisdom of tomorrow.” Sir William Osler, Aequanimitas¹

“The End of History Illusion” is a psychological phenomenon in which people underestimate how much their personality, values, and preferences will change in the future, although they recognize how much they have changed in the past.² In other words, people tend to believe that their current state is likely to persist in the future, so the present moment represents “the end of history.” This phenomenon may lead to problematic behaviors, such as paying too much for a future opportunity and assuming our future preferences will be the same as they are today.² Recognizing this risk, as we make predictions, we will remain aware of our tendencies to assume that our current educational priorities will not change. To start the process, we looked back 13 years (to 2009) and surveyed the neurology educational landscape at that time to appropriately ground our predictions for 13 years from now. Table 1 shows data for various aspects of neurology education from 2009 to 2022 and includes our forecasts for 2035 and some ways we can prepare for these changes.

Table 1.

The Evolution of Neurology Education, 2009–2035, Including Recommendations for Ways to Prepare for Forecasted Changes

Current State

Core Elements of Neurologic Education

“Care more particularly for the individual patient than for the special features of the disease.” Osler, 1899¹

We live in an era of dramatic transformation in the diagnosis and treatment of neurologic disease. Novel treatments such as genetic and cell-based therapies have emerged, there is expansion of the application of neuromodulation, and there are treatments available for a broader range of previously untreatable disorders.^3,4 Beyond advances in clinical science, it has become increasingly evident that optimal patient outcomes depend on a system that ensures equitable delivery of care, and proactively addresses health disparities and social determinants of health.⁵ Health systems science (HSS) has been identified as the third pillar of medical education, and more recently, health humanities (HH) has emerged as a fourth pillar,⁶ with basic science and clinical science being the first and second pillars. HSS and HH offer opportunities to teach the application of knowledge through sharing diverse perspectives, experiences, and reflections. Interprofessional education (IPE), social justice, safety, and quality improvement, and many others that fall under the umbrella of HSS, have been an integral part of the training of undergraduate and graduate medical curricula for years but have often been considered supplemental rather than at the core of the educational experience. For example, many IPE activities have been developed to bring various health profession learners together, but practical and experiential opportunities to apply and engage in these areas are still lacking.^7,8

There has been a long-term recognition of the lack of diversity in the neurology community,⁹ which has had consequences in neurology education, including a lack of mentors and role models, the presence of bias in educational materials, and even what has been published in this journal.¹⁰ Social platforms have provided learners and other stakeholders an ability to organize and share personal narratives resulting in dramatic changes in many aspects of medical education. The American Academy of Neurology has created an anti-racism position statement and an anti-racism curriculum.¹¹ Several academic departments have recognized the need for senior leaders or departmental committees focusing on diversity, equity, and inclusion.^12-14 There are similar efforts to increase education around inclusion and the treatment of gender and sexual minorities¹⁵ and people with disabilities¹⁶ and a general recognition that our learners and clinicians should represent the patients we care for.

How Things Are Learned

“To cover the vast field of medicine in four years is an impossible task. We can only instill principles, put the student in the right path, give him methods, teach him how to study, and early to discern between essentials and nonessentials.” Osler, Aequanimitas¹

An explosion in technology in the past 10 years has allowed for inexpensive and efficient dissemination of educational materials, including video-based lectures, audio podcasts, online modules, assessment materials, and even entire curricula.¹⁷ There is also increasing interest in using social media tools to promote training opportunities, facilitate mentorship and networking, augment learning, or increase engagement with the medical literature.^18-20 Technologic tools have also allowed for broader engagement in global neurology education through virtual shared learning experiences.²¹ For many learners, the process of dissemination of information has moved online.^22-24 There is an increasing awareness of the parallel curriculum involving self-directed and asynchronous learning opportunities so that learners engage with learning resources at times that are optimal for them.²⁵ More attention is being paid to learner-centered pedagogic strategies, including self-paced learning, chunking and bridging (breaking material into manageable segments and providing links between lessons), cognitive load theory (focusing on the difficulty of a learning task for an individual learner), and retrieval practice (repeated retrieval of knowledge as a way to enhance consolidation and transfer).^26,27

Despite the technologic advances in the delivery of educational tools, many successful educational innovations in neurology have been “low tech,” including instruction that focuses on specific patient experiences²⁸ and learning processes that emphasize problem solving and personal responsibility over specific knowledge.²⁹ Although telehealth was already in clinical practice before the pandemic, had it been taught as part of the standard medical curriculum, there might have been a smoother pivot to virtual patient care. Although telehealth competencies have since been published,³⁰ the question remains how and whether telehealth will be implemented into curricula.

The Neurology Educator Workforce

“I desire no other epitaph … than the statement that I taught medical students in the wards, as I regard this as by far the most useful and important work I have been called upon to do.” Osler, Aequanimitas¹

The predicted shortage of neurologists has sparked interest in the neurology pipeline, and the influence of individual neurology educators is a central component of this.^31-33 Over a decade ago, “teacher” and “educator” were synonymous, but with the increased academic recognition of educators, professional development opportunities for educators, and funding for educational scholarship, distinct categories of neurology educators have emerged. Advancement in recognition of educators has allowed neurologists to engage in educational scholarship and step into educational leadership roles locally, nationally, and globally.^34-37 There are emerging distinctions in the different roles that neurologists play as clinical preceptors, teachers, educators, leaders, and educational scholars, each with different support structures, funding models, and criteria for advancement and promotion (Figure 1). Many neurology residency programs have tracks to support a precision education experience for house staff, in which the educational experiences can be tailored to specific career goals.³⁸ Even before postgraduate training, opportunities in college and medical school (e.g., Johns Hopkins Osler Apprenticeship in Neurology) have emerged to expose learners to neurology education and educational scholarship. Programs to foster professional development and leadership have emerged locally and nationally, providing opportunities for neurologists and health professionals in neurology at all stages of their careers to be mentored and developed as educator leaders.^39-41

Figure 1. Description of 4 Main Subtypes of Educational Roles Within Neurology, Including Expectations for Training, Activity, and Advancement.

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Assessment and Educational Outcomes

“Regarding examinations, I have 1 question to ask—Are they in touch with our system of education? And one suggestion to make – That from the day he enters the school, in laboratory, classroom, and wards, the work of the student should count, and count largely, in the final estimate of his fitness.” Osler, 1913¹

There have been dramatic changes in student and resident assessment in the past 2 decades, with an increased emphasis on competency-based medical education (CBME) in both UME and GME.^42,43 On the graduate side, there have been 2 iterations of the Neurology Milestones in the United States,^44,45 and a set of entrustable professional activities (EPAs) and competency-based outcomes have been outlined by the Royal College of Physicians and Surgeons of Canada.⁴⁶ Although there has been some work to provide validity evidence for other milestones,⁴⁷ this is often limited to a description of the progression of residents within the milestones framework or performance on certification examinations, but not to broader educational outcomes after graduation.^48-50 Despite the early promise for competency-based education to result in potential time variable training,⁵¹ the shared mental model for the developmental progression of a neurology resident remains mainly time based.⁵² One study of multiple pediatric residency programs showed that the milestones were more sensitive to differences between programs than to differences between learners,⁵³ and an earlier validity study of internal medicine milestones reported that the differences in overall program milestones scores could be correlated with other program characteristics such as certification examination pass rate or program director experience.⁴⁹ Clearly, the milestones do not represent the totality of what makes an effective neurologist, and there are limited data on how CBME might affect patient outcomes.

Forecasted Developments and Planning for the Future

Core Elements of Neurology Education

Neurologic science will remain at the core of neurology education, but newer aspects of medical education will be integrated into every aspect of our educational mission across the continuum. HSS and HH will provide additional frameworks to ensure that our graduates can provide system-based care and develop a patient-centered professional identity. Local educators and teachers trained in HSS and HH will encourage the exploration of lived experiences, welcome a diversity of perspectives, and foster reflection in a psychologically safe learning environment. Precision education will develop further as learners are encouraged and coached to develop unique strengths in their areas of interest, which will undoubtedly be broader than any specific medical specialty. The future learners will be trained to be “systems citizens,” not only trained to be systems thinkers but also to promote systematic change.⁵⁴ Learners will develop knowledge and skills that allow them to connect with patients in more meaningful and intentional ways, achieving a “personomics” approach to precision medicine.⁵⁵ We will need to ensure that every aspect of neurologic education incorporates health disparities and principles of inclusiveness and equity, and this will require building local and national expertise through best practice guidelines, curricula, and educational tracks. HSS and HH distinction tracks are already being implemented to train the next generation of clinicians.

How Things Are Learned

A predicted explosion in novel neurologic treatments will mean that there is more to know than ever before and more treatment options available to every patient. An aging population will lead to an increased prevalence of neurologic disease and, as such, an even greater need for neurologic expertise in both neurologists and non-neurologists. It will not be possible for all this to be learned in medical school or residency, and so, the educational focus will be on how to learn rather than what is learned. The master adaptive learner model provides a guide to the characteristics of the neurology learner of the future.⁵⁶ We will provide learners from across the educational continuum with strategies on coping, professional identity development through vulnerability, identifying and leveraging their strengths and the strengths of others, communicating, connecting, and promoting a sense of belonging. There will be an increased emphasis on educational models that encourage not just learning but thriving.⁵⁷

The future will also bring a lively discussion of how to ensure that technology is integrated into our core mission. Technologic tools such as video lectures, online tutorials, and podcasts will be implemented deliberately to reduce cognitive load through prework so that learners can engage more deeply in their clinical experiences and their teacher-learner relationships. National and international organizations such as the American Academy of Neurology have the opportunity to invest in the development of a “shared curricular ecosystem,” in which high-quality resources (modules, curricula, and assessment tools) are quickly sorted and searched so that the best options are available to a broader range of learners, transcending traditional institutional boundaries.²³ Local institutions and national organizations can also support faculty development, so talented educators can easily identify ways to share their curricular innovations across institutions.

Relieved of the burden of creating the new teaching content, teaching neurologists will use their time to share their wisdom and experience in case-based discussions, mentorship and coaching, and patient encounters. Far from devaluing the importance of our in-person interactions, if used correctly, technology can allow for the re-emphasis of the most essential role of our clinical teachers, that of a guide and mentor: someone who can impart wisdom and experience and inspire future neurologists and clinicians alike. Individual teachers can spend more time focusing on emerging and nuanced core curricular elements, including health disparities, personalized medicine, and the “personomics” approach to career development. Within institutions, there will be a greater need for neurology educators with specific training in learning and educational strategies. It will no longer be acceptable to depend on experts from other disciplines when developing educational strategies in neurology: teaching and learning will be optimized when there are individuals who have both content and process expertise.

The Neurology Education Workforce

Looking ahead, most educators and educator scholars will require formal training (e.g., graduate degrees or structured professional development), including leadership training. Educators will have come together interprofessionally under one name: Health Professions Educators. With the unification of educators across professions and specialties, a new community of practice will emerge. Convergence into 1 group will allow for leveraging of resources, meta-data, skillsets, and perspectives to develop a core foundation for all health professions so that students in different professions learn with and from each other in a standardized manner. Core curricula will be created and curated by national and global health professions educator scholars and leaders anchored and mapped to existing accreditation standards. Educator leaders will focus their curricula on teaching the learners how to learn and adapt. Educators trained in coaching and mentorship techniques fostering personal and professional growth will be a mainstay so that the next generation will feel the freedom to develop themselves and not feel pressured to fit an outdated career development model. Many more neurology educators will become educator scholars, contributing to research and innovation in health professions education and inspiring transformative change. Educational leaders in neurology will take larger organizational roles across the educational continuum and will be in a position to advocate for a workforce that is optimally suited to the growing burden of neurologic disease. There may be a limit to the number of neurologists we can train, thus neurology education leaders will have to advocate for better education of non-neurologists in the management of neurologic disease.

There has been an increasing recognition of the need for formal support for the educational mission in neurology. Although a few formal roles (clerkship director and program director) typically have institutional financial support, there is often little or no support for other educators, even those with substantial roles. We predict that medical schools will continue to recognize the need to support core educators, with additional defined roles such as academic coaches and exemplar clinical teachers. Neurology educators should work within their national and international organizations to share best practices on the funding of education. Some institutions have formal “clinician educator tracks,” whereas others continue to have a single promotion track but recognize an educator pathway where individuals can showcase their influence, scholarship, and innovation in education. Local and national financial, logistical, and professional support will be needed to encourage the growing group of neurologists who focus their careers on education and teaching.^58,59

Assessment and Educational Outcomes

We predict that there will be an ongoing shift toward holistic assessments by Clinical Competency Committees and equivalent assessment groups in other countries and jurisdictions, based on assessment data that are derived from direct observation, including workplace-based assessments and simulation. This assessment structure will require tremendous resources, and currently, the use of workplace-based assessments is constrained by limitations in data collection, technology that is easy to use and implement, and faculty development.^60,61 There will be an active discussion about the balance between the administrative burden, technologic complexity, and cost of obtaining granular direct assessment data and the potential benefits to patients. Structured and formalized assessment strategies will likely play a more significant role in the future because of the ability to standardize the experience and reduce bias and because this allows for much more direct comparison between learners. Simulation is a promising assessment format not only for both technical skills, such as lumbar puncture and brain death determination, but also for less easily assessed skills such as communication and monitoring peer wellness.^62-64

We predict that there will be an ongoing lively debate about what is expected of every graduate of a neurology residency program. For example, it is unclear whether every graduate would be considered qualified and competent to interpret EEG or EMG.⁶⁵ One model that could be considered is a series of “special qualifications” in specific tasks, which could be earned during either core residency training or fellowship. Such qualifications could serve as a motivation for highly engaged residents to pursue extra training and could help to standardize training and assessment. Providing latitude for training requirements at the level of individual residents can make sense, especially for those residents who have demonstrated proficiency in core competencies earlier in their course of training. For example, it may be consistent with a program's educational mission to provide a resident who is intent on a career as a physician scientist with extra time to pursue research. However, this research time may come at the expense of additional clinical experiences, and programs and credentialing organizations will have to consider the possibility that this resident will later change course (either because of changing life circumstances or lack of research funding support) and focus primarily on clinical care. On graduation, the presumption is that a neurologist can practice in any environment, and we predict that the required training for a physician scientist will be the subject of ongoing intense discussion. There is a substantial risk of “unwarranted variation” in educational experiences, which could amplify practice patterns that are not optimized for the best patient care.²¹ There is more to clinical education than a list of milestones, EPAs, or subcompetencies, and we think it is unlikely that time-based training requirements will be abandoned. However, there are likely to be increasing expectations on programs to document how they are using the training time and assessment systems to prepare graduates to practice in a variety of clinical settings.

We anticipate that there will be a steadily increasing demand for the analysis of educational outcomes beyond the conclusion of training, especially outcomes directly connected to patient care. Although many educational programs track the academic progression of their trainees (e.g., university positions, grants, promotion, and leadership), it is rare to track clinical performance beyond rudimentary measures such as board pass rates or the most extreme outcomes such as formal professional actions or legal proceedings. We predict that there will be an increasing emphasis on tracking educational outcomes that are linked to the needs of our patients and society.^66,67 These outcomes could include the practice patterns, subspecialty choice, location of practice of individual trainees, or even outcomes from national practice registries.⁶⁸ The burden of this data collection cannot lie within individual programs or institutions, and there will be a need for investments in data infrastructure to make meaningful conclusions about the impact of educational programs on patient care.

Conclusion

The future of neurology education is the future of neurologic care. With each adjustment in our educational approach, we must consider how these changes might affect patients with neurologic disease. Although we anticipate some significant changes in what is learned, how it is learned, and how teachers and educators will be involved in this process, we believe that individual relationships will be at the core of all that we do. Social change, world events, and the growth of knowledge, technology, and innovation have profound effects on neurology education, and there is no doubt that more change will occur. The importance of our relationships—between teacher and learner, mentor and mentee, educational programs and society, and especially physician and patient—will remain constant and will be at the core of why we can continue to say “yes” when asked if our graduate should be able to provide care to all our loved ones.

Glossary

CBME

competency-based medical education

EPAs

entrustable professional activities

HH

health humanities

HSS

health systems science

IPE

interprofessional education

Appendix. Authors

Study Funding

The authors report no targeted funding.

Disclosure

The authors report no relevant disclosures. Go to Neurology.org/N for full disclosures.