New Proposal for a Single Neuro/Psych Residency Program

A group of pre-eminent neurologists and psychiatrists have developed a proposal for a single neurology and psychiatry residency program.

A residency in "brain medicine" would educate residents in both psychiatry and neurology and include 2 years of common and urgent training in aspects of neurology and psychiatry, followed by another 2 years of elective subspecialty tracks.

Modern advances have led to "unprecedented knowledge of the brain, which inevitably contribute to the convergence of neurology and psychiatry," the article's lead author, Joshua C. Brown, MD, PhD, director of transcranial magnetic stimulation, McLean Hospital, Boston, Massachusetts, told Medscape Medical News.

However, neurology and psychiatry training programs continue to follow an "outdated" divergence between the disciplines, to the detriment of many patients, Brown added.

"We propose whole brain competence, which would be acquired by "developing programs that are feasible in duration and practical in implementation," said Brown, a faculty member at Harvard Medical School.

The article was published online April 6 in the Journal of Neuropsychiatry and Clinical Neuroscience. Its authors include Mark George, MD, distinguished professor of psychiatry, radiology and neuroscience, and director of the Medical University of South Carolina Center for Advanced Imaging Research and the Brain Stimulation Laboratory, and Nolan Williams, MD, associate professor of psychiatry and director of the Brain Stimulation Lab at Stanford University.

Blurred Lines

The proposed program encompasses the structure and the function of the brain. Historically, these have been viewed as disparate entities, with "structure" accorded to neurology and "function" to psychiatry.

However, there are no defining rules to divide brain disease into these two categories, and the "neuroscientific revolution is erasing the line drawn between disorders of structure and function," the authors write.

"With advanced brain imaging, neurophysiological techniques, sophisticated animal models, and cell cultures, it has become apparent that all brain disorders have their basis in brain structure and that all brain disorders affect brain function," they write.

The artificial distinction between psychiatry and neurology means many patients' needs go unmet, said Brown.

"What really motivated pushing this article forward and moving in this direction was the recognition that, on a very practical level, things are being missed and patients' needs are falling between the specialties," said Brown, whose own residency at the Medical University of South Carolina was a 6-year program in neurology and psychiatry.

The prevailing wisdom is that patients who fall between neurology and psychiatry are "niche patients with unusual neuropsychiatric disorders." But in fact, said Brown, "patients whose conditions cross both specialties are the rule, not the exception, and diagnoses and appropriate treatments are often missed or critically delayed."

He gave an example. "I was seeing psychiatry patients in the ER and a patient came in with confusion. It seemed like a psychotic presentation."

Brown was asked to admit the patient to the psychiatry service. "But I noticed that when he got out of bed and walked, he had a magnetic gait, which is one of the classic triad of features of normal-pressure hydrocephalus." Now accurately diagnosed, the patient was treated for this condition.

However, Brown noted, if his patient's condition had been diagnosed as psychiatric, "he likely would have been admitted to the psychiatry unit and treated with antipsychotics, which wouldn't have addressed the actual problem, and then [he would have been] labeled as 'treatment resistant.' " He attributes his ability to accurately diagnose this patient to his training in neurology.

Practical Considerations

The authors propose a 4-year program which, instead of providing a limited amount of training in every subspecialty of neurology and psychiatry, would focus on "important foundational aspects of the brain" that manifest in an array of conditions.

The program wouldn't require dismantling of current departments or undoing the development of any specialty or field but rather build on the current foundation, said Brown.

The structure and content of the proposed program are as follows:

Years 1 and 2

"Brain Medicine Core"

· General medicine (4 months)

· Primarily inpatient psychiatry (10 months)

· Primarily inpatient neurology (10 months)

Years 3 and 4

· Epilepsy and neurophysiology

· Outpatient psychiatry

· Geriatric psychiatry

· Behavioral neurology and neuropsychiatry

· Interventional psychiatry

Years 5+ (optional)

· Psychoanalysis

· Child

Similarities and differences between existing and proposed residency programs are listed below.

Similarities

Differences

· 4-year duration

· General medicine requirement

· Inpatient care predominates during the first 2 years, leading to "senior resident" status

· The last 2 years include outpatient and elective rotations

· Accreditation Council for Graduate Medical Education (ACGME) requirements, goals, and competencies fulfilled for psychiatry and neurology

· Continuity clinics included for both specialties

· Options available for those seeking to pursue fellowship training

· Graduates become board-eligible

· Board certification through the American Board of Psychiatry and Neurology (ABPN) remains the same

· Reduced general medicine requirements

· Inpatient neurology and psychiatry during first 2 years

· Subspecialty tracks, with training more individualized during the last 2 years

· Brain medicine boards encompassing both psychiatry and neurology

· Exposure rotations during year 1

The authors propose "Brain Medicine" as the name for the new residency program "to not only cross the traditional boundaries of neurology and psychiatry but also encompass and unify these disciplines, and emphasize the biological basis of function and behavior," said Brown.

Current Model Detrimental

Commenting for Medscape Medical News, Casey Halpern, MD, associate professor, department of neurosurgery, Crescenz VA Medical Center, University of Pennsylvania, Philadelphia, said the proposed merger of psychiatry and neurology is "timely."

"As we've been learning more about the brain, the distinction between psychiatry and neurology is "becoming a detriment to patients with brain disease."

Halpern, who was not one of the article's authors, said he hopes medical school chairs of psychiatry and neurology will "prioritize the needs of the patients and the education of physicians and figure out a way to make this type of merger financially viable." However, he added, "it will take a lot of time to figure that out."

Also commenting for Medscape Medical News, Sheldon Benjamin, MD, vice chair for education and associate training director, psychiatry and neurology, department of psychiatry, UMass Chan Medical School, Worcester, said the authors are "doing a service to the field by fomenting this discussion. We need people to take outside-the-box positions to drive the field forward, sort of like the grain of sand in the oyster that causes a pearl to form."

Benjamin agreed that physicians "need to look beyond the classical bounds of the specialties of psychiatry and neurology to treat patients whose disorders do not respect those boundaries."

Although psychiatry and neurology residencies both need to incorporate more training in their respective complementary fields, the specifics of the authors' solution "would amount to watered-down training in both fields."

It is unlikely, he said, that a graduate of the proposed 4-year program would be able to conduct insight-oriented psychotherapy independently or a thorough differential diagnosis of neurological complaints.

That said, Benjamin acknowledged the authors' point that there is a "tendency toward subspecialization and that graduates of 4-year residences often undertake additional fellowship training in any case."

Brown has received research grant support from the National Institute on Drug Abuse and the national Institute of General Medical Sciences. The other authors' disclosures are listed in the original article. Benjamin is a partner in and author for Brain Educators LLC, publishers of The Brain Card (a neuropsychiatry examination pocket card) . He is also one of the psychiatry directors of the American Board of Psychiatry and Neurology, for which he receives a small stipend. Halpern is a consultant for Boston Scientific and Insightec and is also the chairman of SynchNeuro.

J Neuropsychiatry Clin Neurosci. Published online April 6, 2023. Full text

Batya Swift Yasgur MA, LSW is a freelance writer with a counseling practice in Teaneck, NJ. She is a regular contributor to numerous medical publications, including Medscape and WebMD, and is the author of several consumer-oriented health books as well as Behind the Burqa: Our Lives in Afghanistan and How We Escaped to Freedom (the memoir of two brave Afghan sisters who told her their story).

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