N.B. It is very important that the applicant apply to PGY-1
(internal medicine) programs at the same time as the Neurology
program. Some neurology programs include a PGY-1 year within
their program (integrated programs). When making plans to apply and interview at Neurology
programs, the applicant should inquire about internship opportunities
in the area and apply and interview as required.
Interviews
Interviews begin in October and run through mid-January. You
should expect to be interviewed by 2-6 people at each visit,
and you will meet the program director and chairperson everywhere.
It is best to communicate with each program to get an idea
of scheduling requirements. During the 1999 Neurology Match,
the average number of program applications per applicant was
17 and the average number of interviews per applicant was 4.8.
This seems like a large number of applications and may be skewed
by a subset of applicants who send off a very large number
of applications.
Programs will invite applicants for interviews based on their
submitted credentials, personal statement and letters of reference.
The interview and visit to each program is the best opportunity
to gather more information; use this opportunity to its fullest.
Applicants should prepare for interviews by reading about the
programs and have a list of questions ready. Meeting with the
housestaff to get their candid impressions of the program is
an important part of the interview process.
National Resident Matching Program
Detailed information about the match
is available from the National Resident Matching Program (NRMP) website: www.nrmp.org/
Detailed information about the residency application process is available from the Electronic Residency Application Service (ERAS), sponsored by the Association of American Medical Colleges (AAMC) website: www.aamc.org/audienceeras.htm.
Matching Program Timetable
(A more detailed table is available at ERAS: http://www.aamc.org/students/eras/timeline/start.htm )
| May/June |
Request information and applications from training programs
of interest. Inquire about each program's typical interview
schedule and deadlines for application submission. |
| Summer |
Gather letters of recommendation, supportive documentation,
and complete applications. |
| August 15 |
Applicant registration through ERAS begins at 12:00 noon eastern time. |
| September 1 |
Target date for submission of application to ERAS |
| December 1 |
Applicant registration deadline; a late fee applies after this date. |
| Oct/Nov/Dec/Jan |
Programs conduct interviews |
| January 15 |
Rank order list entry begins. Applicants may start entering their rank order lists at 12:00 noon eastern time. |
| February 21 |
Rank order list certification deadline. |
| March 15 |
NRMP Match. Match results for applicants are posted to the R3 System at 1:00 p.m. eastern time. |
The information above was obtained from the NRMP and AAMC websites.
Other Match Information
The Match process in Neurology is generally quite favorable. The percentage of U.S. medical school seniors matching to programs has generally been 95-98% in the past ten years.
(back to top)
Chapter 2:
Electives Useful to the Medical Student/Future Neurologist
Generally,
my advice is for students to avoid electives in neurology!
At the very least, you should balance neuroscience-oriented
electives with electives in non-neurological areas. Remember,
you will do at least 3 years of full-time neurology training,
during which you will learn the skills you need to be a good
general neurologist. Look on your medical school elective
time and internship elective time as opportunities to learn more
about things outside of neurology.
I would encourage you to think about electives where, for example,
a neurologist may be consulted but may not serve as the primary
physician. This might include areas where you may not do formal
rotations during internship or residency. Options include cardiology,
especially ECG interpretation, since you will often care for
patients with cardiac disease during your training. Also, neurologists
are often consulted for patients who lose consciousness, and
cardiac problems are probably the leading cause of syncope. Consider
also a rotation in emergency medicine. Many neurologic consultations
take place in the ED, and understanding the perspective of the
emergency physician when obtaining neurologic consultation may
be helpful. It could also provide you with some background on
managing neurologic emergencies. Critical care medicine is another
useful overlap area with neurology. Many patients in ICUs wind
up there because of a primary neurologic disease (e.g., stroke,
hemorrhage) or later develop neurologic complications unrelated
to their primary diagnosis (e.g., critical care neuropathy, delirium,
coma). The best neuro-critical care consult probably comes from
a neurologist who understands the basic principles of critical
care.
For neuroscience-oriented electives, I would suggest thinking
about how you might go back and review basic neuroanatomy. A
sound knowledge of neuroanatomy is the basis for accurate localization
skills. Possibilities include spending time with Dr. Powers in
neuropathology, with special emphasis on the gross brain dissections.
Alternatively, depending on the timing, perhaps Dr. Jozefowicz
could use your help in the neuroscience lab during the Mind,
Brain & Behavior course. Another possibility might be a special
elective tailored to your individual interests and background
during which you could spend some time reviewing basic neuroscience
principles that would be of use to you in your future training.
I could imagine such an elective involving, for example, directed
readings and lab work under joint mentorship from, say, Dr. Jozefowicz
and Dr. O’Banion (although there are undoubtedly many faculty
who would welcome the opportunity to mentor you in such an elective).
________________________________________________________________________________
Outpatient electives are much more a reflection of what practice
is like. Choose a busy practice, perhaps with someone who has
recently left academics, or at least has a reputation for teaching.
An elective to the National Hospital for Neurology in London
will forever alter the way you look at Neurology. I wish I had
more exposure to psychiatry, particularly so-called liaison psych.
A time working in a reputable lab is useful to get a perspective
on the molecular basis of neurologic disease. It will also help
you decide whether lab work may be something you want to pursue
later, and will guide your choice of residency programs. Choose
if possible a lab where there is a national figure working on
a particular disease. Follow them from the lab to the clinic.
________________________________________________________________________________
I thought cardiology, endocrinology, rheumatology and ED (required
here) were all helpful.
________________________________________________________________________________
When you choose your electives, do things that you will NOT
have time to do again. If you want to have experiences to talk
about for a neurology interview, choose related subspecialties
such as neurosurgery, pediatrics, psychiatry or any medicine
subspecialty.
________________________________________________________________________________
There were very few electives available to us in medical school.
It was a rather restricted curriculum with the first two years
being preclinical and the last two clinical. However, during
my last year I did take a course in advanced neuroanatomy for
the graduate students. I became interested in neurology in the
first year of medical school after the neuroanatomy course. I
was intrigued by the instructor and came back later to take a
Ph.D. under his tutelage. I am not sure what advice I would give
to a medical student now. I don't think it was particularly necessary
to take extra neurology beyond what you are getting. However,
you get a very good experience in neurology at the University
of Rochester. I would guess that at some schools this is not
the case, and in that instance, if they do not have elective
time, they should do a clinical clerkship in neurology.
_______________________________________________________________________________
I really don't think it matters what you take in your fourth
year. Just make sure you really want to do neurology. You could
take some easy outpatient electives or go into a private neurologist’s
office to see how things are in "the real world."
______________________________________________________________________________
Cardiology was the most helpful elective. Both invasive and
noninvasive aspects of cardiology are relevant to neurology,
especially to stroke. Immunology/Rheumatology is also very useful.
Many of the evolving treatments involve autoimmune diseases.
Hematology: have a good grasp on diseases of hypercoaguability.
________________________________________________________________________________
You can't get enough anatomy: if you get a chance, take electives
in neurosurgery and radiology. Take an elective in neurosurgery
where you will learn the discipline-- not just how to scrub in.
Don't forget to learn the things that you will never get a chance
to learn again. Even if you know you want to do neurology, take
the time and put in the energy into learning your other coursework,
obviously medicine, but things such as OB as well. Psychiatry
and neurology go hand in hand. It's getting harder to differentiate
between the two; each has the other as a major comorbidity. Learn
them both.
_______________________________________________________________________________
Orthopedics, given that neurologists need to know the musculoskeletal
system to evaluate the neuromuscular system.
(back to top)
Chapter
3: Appropriate Textbooks, Journals, and/or Other Resources for
Medical Students
This
is always a tough one, because every individual has their own
strengths and weaknesses. I suggest a plan of starting out
simply and becoming progressively more refined in your reading.
Furthermore, every book or journal has its own strong points.
I will try and summarize some of these below.
Books
1. Brief & Introductory
All of the following are (relatively)
inexpensive. Neurology for the House Officer has good,
basic information that will give you a starting point for common
neurologic
complaints. It can be read quickly, and fits nicely into a coat
pocket or instrument bag. Neurology On Call can help
provide some reassurance during those scary first few months
when you
have suddenly gone from medicine intern to “the” neurologist
for the hospital! It is simple, problem oriented, and tells you
the first things to think about in urgent situations. The
Little Black Book of Neurology by Lerner is good and contains
much useful information. It is something you can read in a couple
of weeks
and get a solid overview of major neurologic syndromes, problems,
evaluation, and basic treatment. The problem is it is alphabetical
by subject, so when you’re just starting out and don’t
yet know the diagnosis, it can be hard to find information. The
Handbook of Symptom Oriented Neurology by Olson et. al. is useful
in that it provides a symptom based, problem oriented approach
to common neurologic complaints. The limitation is that it is
not very comprehensive, but it would be a fine way to start reading
about neurologic complaints and their evaluation.
2. More Detail, Still Introductory
For a more refined but still
introductory approach, I really, really like Practical
Neurology edited by Jose Biller. The title
says it all. The book deals nicely with common neurologic diseases
and the most common
treatments. I think every neurology resident should read this
book during
their first couple of months of residency! A good alternative
is Clinical Neurology by Greenberg et. al. This is
still in outline format (like Biller) but has more text and
more diagrams.
(Despite
that, Biller is still my personal favorite.)
3. Intermediate
Once you are comfortable with the basics, an
absolutely essential book is Localization in Clinical Neurology by Brazis et al. This is a very, very nice book that you can
refer to over and over again for clinically oriented reviews
of neuroanatomy and how lesions will manifest under different
circumstances. When you have advanced somewhat in your training
and are doing neurology consults, Neurology and General
Medicine by Aminoff is an absolutely outstanding text that talks about
neurologic manifestations of non-neurological diseases.
4. Comprehensive
At some point, you will want to get a copy
of one of the standard big neurology textbooks. All of these
are expensive. Depending on your ethical views, many residents
hit up the drug reps for copies of these books. They are Merritt’s
Neurology by Rowland, Principles of Neurology by
Victor & Ropper,
and Neurology in Clinical Practice by Bradley et. al.
Merritt’s is nice because it is concise and clear with
lots of tables. A paperback handbook was recently published which
is also helpful, but is mostly just an outline of the larger
book with little accompanying text. The limitation I find with
Merritt’s is that you almost have to know the diagnosis
before you can look anything up. Of course, if you do already
know the diagnosis and need to read about the disease, this is
a great resource.
Principles of Neurology is a highly regarded text by
very seasoned clinicians. Its major strength is that it is very
much problem
oriented, so you look up a general problem (e.g., "weakness”)
and you get a huge discussion of the many things that this can
signify. The limitation, of course, is that you get huge chunks
of information! Sometimes you get too much. I also find the writing
style somewhat “stuffy” and old fashioned, but that’s
a personal matter that may not be a problem for others. They
recently published a handbook to this text that looks pretty
good. It limits itself to the major problems one encounters,
and has more text than the Merritt’s handbook.
Neurology in Clinical Practice is an outstanding book, and my
personal favorite among the big tomes. Do not make the mistake
I did for years: I was put off by the fact that it is two big,
heavy volumes. It looks very imposing, but is the most user friendly
neurology book I have found! In my opinion, it combines the strengths
of both Merritt’s and Principles without any of the limitations.
Each volume is broken down into nicely digestible chapters that
are well written, well illustrated, and that have plenty of good
summary tables, charts, and flow diagrams. The first volume deals
mainly with how to approach various complaints and establish
a good differential diagnosis. The second volume is organized
around disease processes. This book has a handbook with it, too,
but I have not read it. There is also a small workbook of practice
questions with annotated answers that could be useful for in-service
exams or the neurology boards, but I have not used that book
either. I would advise residents to get this book sometime toward
the beginning of their neurology residency, and set a reading
schedule (maybe with some other residents) with a goal of trying
to read the book during three years of residency. That’s
a very reasonable goal, I think, and would provide an excellent
background.
Journals
There are lots of great journals out there, and not
enough time to read them. When starting out in neurology, much
of your
journal reading will be guided by your upper level residents
and attendings. You will learn what journals publish articles
on topics of interest to you.
Also, some journals will probably
be supplied to you during residency by pharmaceutical companies.
Some of these are quite
good. Journals that were given to me free were Seminars in
Neurology,
The Neurologist, and Continuum. Each of these is excellent, and
I recommend reading them or at least hanging on to them if they
are given to you. Continuum may initially seem way too detailed
for you as you begin your training, but don’t throw it
out! Continuum is absolute gold when you are studying for your
neurology boards at the end of residency.
I am really a big fan of The New England Journal of Medicine.
To me, the review articles alone are worth the subscription price.
These often focus on important neurological topics. You also
get a sense of how all of medicine is developing, even if you
don’t read the non-neurology research articles in depth.
Neurology, which is produced and edited here at the U of R by
our chairman, Dr. Griggs, is the flagship journal of our field.
You can get a subscription by joining the American Academy of
Neurology, and it is worth it. Again, some of the research articles
won’t be of use to you early on, but there is at least
one good review article per issue, and they also publish practice
guidelines for various diseases. You probably won’t read
every issue cover-to-cover, but you should at least scan it.
Archives of Neurology is another of my favorites, and, to my
eye, the most visually appealing of the neurology journals. Good
research articles as well as good reviews.
Neurologic Clinics is a great resource for in-depth discussions
of particular issues. Probably too much detail early on in
your neurology career, but keep it in mind if you need an
in-depth
review.
My suggestion when you are starting out is to scan the New
England Journal, Neurology, and Archives on a regular basis. Pay particular
attention to the review articles, as they tend to focus on common
neurologic entities and are usually written by leading authorities
in the field.
________________________________________________________________________________
Dr. Jozefowicz’s syllabi are very good. Know your basic
anatomy-based differential diagnoses for common neurological
conditions (localize!). Journals: New England Journal of
Medicine is the best general medicine journal. Its clinical
correlation series has many cases relevant to neurology. The Neurology journal
(Editor: Griggs, our chairman) is a good source to see directions
research is going in neurology. Just skim the
abstracts, or dive in only when a topic intrigues you. The
website lets you browse articles since 1996 by topic. Archives
of Neurology has some good reviews of basic topics. B.)
Two good introductory neuro texts are: (i) Practical Neurology by
Jose Biller - superbly organized presentation of topics organized
first by symptom, then by treatment category; (ii) Neurological Differential Diagnosis by
Patten -- superbly written, with skillful illustrations and
useful case studies. The two
standard advanced texts are, of course, Adams and Victor and Merritt’s.
A relative newcomer that many neurology residents consult is Neurology in Clinical Practice by
Bradley et. al, out of U.C.S.F. The standard neuroradiology
text is Diagnostic
Neuroradiology by Anne Osborne. If this intrigues you,
do a 1-2 week elective in the neuroradiology reading room.
________________________________________________________________________________
It would also be worthwhile to make relevant connections within
your clinical experiences throughout medical school with nervous
system connections. I believe that general texts in neurology
would be more helpful than specific journals. Relative to journals,
a walkthrough the new and recent journal displays in the Miner
Library would provide you with a sense of background of the
broad scope of literature related to the nervous system and
clinical neurology. Similarly, browsing in the history of medicine
section would provide perspectives concerning the origin and
development of the specialty.
________________________________________________________________________________
I think as medical students you should stick with the basics
and maybe buy a copy of Harrison’s. Use the neurology
section on that to learn. Emedicine.com on the web is great
for articles as well. You should only read journals and such
after you know the basics.
________________________________________________________________________________
I think Merritt’s textbook of neurology is a good starting
textbook because it is easy to read and not too detailed but
gives a good overview of each subject. Journals are too advanced
at this point since you are still trying to learn the basics.
I do often pull review articles from the NEJM as they are aimed
at the generalist physician. Resident rates are pretty good
for this journal and there is online access.
________________________________________________________________________________
Book: Neurology and Neurosurgery Illustrated is
a great start. Journals: Am. Fam. Physician and NEJM CPC’s
are great reviews. Neurology is a very practical source.
________________________________________________________________________________
It is all down to anatomy. If you don’t know your anatomy,
neurology will remain a mystery. I would avoid “pure” neuroanatomy
texts, which lack any clinical correlation. By some distance,
the text of choice is by Patton. Fabulous drawings, which make
you understand the anatomical basis for the clinical exam.
Not that good for discussions on diseases but that can wait.
There is an excellent CD Rom on neuroanatomy by Netter.
________________________________________________________________________________
Students should read texts and one journal such as NEJM.
________________________________________________________________________________
Read the basics. Forget the esoteric at this stage of the game.
Merritt’s, Victor and Adams, Kandel and Schwartz. The
latter gives many neuroscience underpinnings that will always
be relevant. If you read a journal, read basic reviews. The
science and forefront things change so rapidly, that by the
time you get to and through residency, anything “hot” will
be in the textbooks. Unless it was “not.”
________________________________________________________________________________
I think students, as do faculty, have difficulty prioritizing.
There is so much information available that it sometimes seems
impossible to pick and choose. I think it is important that
they get their fundamentals. You can’t be a good neurologist
without a very good basic knowledge of neuroanatomy and neurophysiology.
So I’d spend my time on the basics.
________________________________________________________________________________
Reading should be patient directed (even if it is not “your” patient.)
You have a chance to participate in their care. When you do
read the details are more likely to recall the information
when it is “real.” Start with textbook, then review
articles, then move on from there.
(back to top)
Chapter 4: Essential and Undesirable
Qualities of a Neurology Residency Program
General. Any good neurology
program should always be trying to strike a balance,
weighing residents seeing enough patients
to develop good clinical skills against the need to have
adequate time to read, study, sleep, and live a life. I do
not know
of any neurology program that achieves this balance perfectly.
The
real questions are, how hard are their on-going efforts
to try and maintain this equilibrium, and how close do they come?
Also, keep in mind that residency training is just plain hard
work. No matter how good the program, as a resident you never
get enough sleep; the best you can hope for is adequate sleep.
Also, there is no way to remove stress. As a resident, you are
constantly on the hot seat because you have responsibility for
patients’ welfare, but you’re still learning and
your knowledge of how to take care of patients is, by definition,
incomplete (otherwise you wouldn’t be a resident). So no
matter where you go, the residents will be tired, and they will
be stressed. It is just a matter of degree. A good program has
residents who are tired but not exhausted, challenged but not
overwhelmed, and who can be happy and offer a good endorsement
of the program despite the difficulties any resident faces during
training.
Read Kenneth Iserson’s Getting Into a Residency, but take
each point with a grain of salt. Not everything in this book
applies to every person, but overall Iserson offers good advice
and good general rules for how to organize your thinking about
residency interviews.
Evaluating the program. The only people that can really tell
you about the training program are the residents. Even the
most honest program director with the best of intentions can
only
tell you what he or she hopes the training program is like.
Only the residents know for sure. Therefore, I would look for
the
training program where the residents seem happiest overall.
You should be given ample time alone with at least several of
the residents, no faculty. Dinner before or after your interviews
is a common venue when you can get the scoop on the program.
If faculty are always nearby, that could be a red flag: is there
something they don’t want the residents to tell you?
Residents certainly have their own idiosyncrasies, too, and
you should bear that in mind. One particularly cranky resident
should not necessarily taint your view of the entire program.
Conversely, one especially sunny disposition may be happy no
matter how bad things get. Consensus is the key. Also, be sure
and question why anyone (resident, program director, faculty)
says what they do. Negative comment, ask, “Why do you say
that?” Positive comment, ask, “Why do you think that
is so?” Remember, although you are being scrutinized, you
should also be scrutinizing them.
Insist on meeting the PGY-2 residents at programs you are seriously
considering. Those residents will be your senior residents when
you start your neurology residency, and as such are just as important
as the seniors you are likely to meet when you interview. If
you can’t meet the PGY-2’s, it may be a red flag.
Don’t judge the PGY-2’s based on knowledge, because
they are just starting out. Rather, see whether you think you
would be comfortable with them being your immediate supervisor.
Different personalities work better in different programs. “Know
thyself” is a good rule. For example, a program with a
huge neuro-critical care population may seem more exciting and “sexy” than
a more traditional program, but ask yourself whether you really
want to put in the hours required to care for critically ill
patients. On the other hand, if you live for that adrenaline
rush, you may not be cut out for a program where there are no
critically ill patients.
When considering your personality, consider also the community
in which the program is located. Some residents and faculty will
tell you this is not important, because you won’t have
that much time off as a resident. I disagree. The fact that your
time will be at a premium is all the more reason to make sure
that the place where you are living has the kinds of things you
enjoy doing during your limited free time. If you are an avid
skier, for example, a residency in Los Angeles, Miami, or Houston
is probably not for you. If you enjoy being with family, relocating
across the country is probably not wise. If you enjoy hiking
in the woods, New York City and other huge urban areas is probably
not where you should be looking.
On the other hand, some people use residency as an opportunity
to experience life in some very different part of the country.
If you have always lived in the northeast, maybe you want to
spend a few years in the southwest, for example. Each person
is different. You just have to reflect on what is right for you.
Look also for balance in the program. Are the major subspecialties
of neurology represented (stroke, neuromuscular, pediatrics,
epilepsy, oncology, headache, general neurology, movement disorders,
dementia/behavior, geriatrics, neuroradiology, MS/demyelinating
disease, rehab)? Ideally, you should also interact to some degree
with neurologists in private practice so you get some idea of
what that lifestyle is like. Not every program offers everything,
and 1 or 2 deficiencies may be overlooked, but be suspicious
where there are multiple deficiencies. Such a program need not
necessarily be ruled out, but bears very careful examination
before you should go there. Also, be sure that one subdiscipline
doesn’t dominate to the exclusion of other areas. Remember,
your goal at the end of 3 years is to be a good general neurologist.
If you decide to subspecialize after that, you can get additional
time in a focused area of concentrated study. In addition, you
need at least some exposure to subdisciplines of neurology in
order to make an intelligent choice about whether to do fellowship
training after residency.
For your preliminary year in medicine, you also need a place
with a great Internal Medicine program. A lot of neurology entails
general medicine, so you want to learn as much internal medicine
as you can during internship. The rules for evaluating such programs
are pretty much the same as evaluating a neurology program.
Inquire about didactic sessions at programs. There should be
some protected time for residents each day for learning in journal
clubs, formal lectures, etc. Inquire specifically about protected
time. Many places will tell you, “Oh, yes, we have lectures
every day,” but unless the residents are protected, they
may be constantly called to the ED, ICU, the floor, etc., to
see patients. Also ask how the protection is in place. For example,
it’s not just that you are “allowed” to go
to the lecture…and then you are “allowed” to
stay two hours later that night to finish your work. The issue
is that you are free to go to the lecture and that the additional
time added to the end of your work day is not so onerous that
you can still read, study, and spend time with your family. (Remember,
no matter what anyone tells you, it is not a sin to desire a
life outside of medicine. You should work hard, take good care
of your patients, make sacrifices when necessary, and stay late
when you need to, but you do not sign off from the rest of the
world just to be a doctor).
Ask about the call schedule, who is in charge of it, how flexible
it is, etc. The question is not just how often you are on call,
but also how busy a typical call night is and how acutely ill
the patients are. For example, 3 ICU admissions in one night
can be grueling if they are truly in critical condition. On the
other hand, 8 floor admissions with straightforward problems
may still leave time for a reasonable amount of sleep. Ask the
residents about the quality of the emergency department where
they are, since many of your consults will originate from the
ED. If they call neurology just when they don’t want to
really think about a case, that’s not good. Also ask about
who will be your back up when you are on call. Do you have a
senior resident in-house with you? Is there an attending with
whom you can discuss patients over the phone? How readily will
an attending, fellow, or upper level resident come in during
the night if you get overwhelmed or need help with a case?
Other sources of information. Find residents here at Strong
who went to medical school in places you are interested in applying
to. Even if they’re not in neurology, they probably did
a rotation as a student, and they can give you insight into personalities
and culture of the neurology program at their old schools, as
well as the communities in which they are located.
Faculty can be of help, too, either inside or outside neurology.
Some may have trained at institutions where you want to go, and
they can tell you how neurology is viewed there. Within neurology,
some of the more senior faculty in particular may have experience
with or knowledge of residency programs around the country. Dr.
Jozefowicz is a great resource in this regard, as is Dr. Griggs.
They both travel a lot, know many people in different places,
and see lots of different departments. Remember, though, that
even Dr. J. or Dr. Griggs can’t tell you what the program
is really like as of this moment. Things change, and to get the “inside
story,” you’ll have to talk to the residents.
There are regulations about what kinds of things neurology programs
should do. Read the latest regulations by the American Council
on Graduate Medical Education at their web site, www.acgme.org.
Make sure that programs in which you are interested are in compliance
with the ACGME. If they are not, don’t even go there. Don’t
think about it. Just don’t. It’s a mistake.
________________________________________________________________________________
A good residency program will depend on what you want out of
it. Broadly they segregate in those with strong basic science
faculty and those with strong clinical emphasis. It is rare
to find a program with both. If a student anticipates a career
at the bench, they will naturally be drawn to programs with
this emphasis. All programs will advertise themselves as “clinical”;
many are not. They are headed by faculty with little interest
or experience in patient care. A key issue is: are the residents
happy. Try and seek out recent graduates from the program,
as well as medical students from that school - if there are
a lot applying to their own program, chances are that it is
reasonably good (also tells you that your own chances of matching
may be slim if the program is too incestuous). Talk to younger
faculty at the U of R who have come from other programs. They
will be open with you.
________________________________________________________________________________
The key to a good neurology department is strong general neurology
exposure. If you get that experience, anything you want to
specialize in becomes easy. When you look at the program, evaluate
the faculty, what is their standing, nationally or even internationally.
They will be your mentors beyond your training. Make sure there
is a balance between the inpatient and outpatient experience.
Does the program allow you to grow as a neurologist and give
you increasing responsibility: independence managing your patients
and teaching medical students, interns and residents. How much
elective time is available and what can you do with that time?
Explore further subspecialties, increase neurodiagnostic skills,
research if your are interested in an academic career. Is the
residency director responsive to resident concerns? Make sure
the program does not cover too many hospitals so that you are
stretched to your limits. It is preferential to find a program
that has intern coverage, because you would have already done
your internship and do not want to do it again. The location
should be something to consider also. You will not be spending
your whole life in the hospital. Family life and hobbies are
a consideration. Most places are looking for people who are
willing and able to work hard, be team players and have initiative.
________________________________________________________________________________
Essential qualities: happy residents; large enough so that
you can live with the call schedule; If you are interested
in research: established research labs in your prospective
field(s) of interest so you do not have to re-invent the wheel;
If you are interested in clinical neurology: a sufficient mix
of outpatient experience; neurologists on staff that sound
like they not only know neurology, but they are interested
in teaching it and are good at this. Undesirable: unhappy residents;
absence of any else of the above; significant part of the neurology
staff in flux (especially the chairman or residency director).
________________________________________________________________________________
I suppose it depends on what is important to you. I felt that
feeling comfortable with the residents was very important.
I interviewed at programs where the residents did not seem
happy or interested or were over stressed and I ranked them
lower. Second would be to find a program that makes residency
education a priority. This is the time to learn neurology whether
you plan an academic or private practice career. Ask about
board pass rates, structured activities for resident education,
do the residents actually attend these conferences or are they
too busy answering pages and running around. Make sure there
is adequate patient contact and a good variety of patients.
Also make sure that the faculty are also diverse; you want
most of the specialties well represented to maximize your training.
________________________________________________________________________________
I personally think that any program that crams all of the call
in the first year is doing a disservice to the residents. You
learn different things at different stages of your training
and I think you get more out of having it spread over two years.
Having medicine interns rotate is very helpful, i.e, you don’t
want to be an intern twice! so avoid programs that don’t
have medicine interns.
________________________________________________________________________________
Avoid departments with only one or two foci. Aim for departments
that have subspecialists in at least four of the major neurology
subcomponents: epilepsy, neuromuscular, neuroimmunology, movement,
neuroophthalmology, neurootolgy, neurooncology, headache, stroke,
child neurology, autonomic nervous system, infectious disease.
________________________________________________________________________________
Pick a place where you will work the hardest but still enjoy
it. Experience is the best teacher. Pick a place where you
like the people you work with and feel like you fit in. You
will spend too much time at work to dislike the people you
work with. It helps to like the location as well. Pick a place
with a good enough reputation to open doors for you—fellowship
or otherwise. My estimate is about ¼ of neurology programs
should be closed.
________________________________________________________________________________
In regard to residency applications, I think the qualities
of a residency program are, first of all, a very heavy exposure
to patient care. My old chief said that if you can read a journal
or see a patient, go see a patient and you will learn more.
Also, I think it is important in the outpatient setting that
you have continuity of care over a number of years with your
patients. This gives you a feeling of the evolution of many
chronic diseases. I don’t know if there are any particular
undesirable aspects to a neurology program, but I think clinics
where you have brief exposure to patients and not continuity
of care are bad.
________________________________________________________________________________
Try to apply to a variety of types of programs (big, small,
etc.) to help you decide what you like and don’t like.
Ask lots of questions—what kind of patients do they get in
their continuity clinic? what kind of contact do the residents
have with attendings? who is your backup if you run into a
problem on call?
________________________________________________________________________________
It is essential that opportunities exist for patient care in
all settings, particularly the ambulatory setting. Sufficient
attending supervision for purposes of confirmation of a resident’s
observations and consultation when necessary regarding diagnosis
and management are important. As is the case in making medical
school decisions the best information regarding your residency
experience is derived by meeting residents participating in
a program. The opportunities within the program for clinical
and/or laboratory research should be explored depending on
one’s interest. It is also important to assess the amount
of educational activity incorporated each week as part of the
busy schedule of the house officer.
________________________________________________________________________________
Obviously, you need to find the program that fits your needs
best. Some things to keep in mind when looking at programs
are:
(back to top)
Chapter 5: Student Preparation for Neurology
Residency
You will
already have done a lot of work as a student. The training that
you get here at the U of R is really excellent, so you have
a great foundation on which to build. Round out your experience
with a balanced selection of non-neurology oriented electives
(see above), but treat yourself to a good neuro elective if
there’s
something in particular you want to brush up on.
After that, find good preliminary internal medicine and neurology
programs that fit you. Your requirements will be different from
every other person. Making this decision is just as personal
as your choice in college to go to medical school, so know what
kinds of things you want out of yourself and a program.
Aside from these very basic comments, there’s nothing
special you need to do. You will be prepared with adequate knowledge,
so don’t worry about that. As for the mechanics of being
an intern/resident, you can’t prepare in advance, but don’t
worry. We all survived it, and you will too!
________________________________________________________________________________
Do enough neurology that you are sure this is the career
you wish to pursue. Get to know the faculty and residents
of the
program at your medical school.
________________________________________________________________________________
Graduate from UR medical school with Ralph Jozefowicz as
your teacher.
________________________________________________________________________________
Preparation: Establish that you are interested in neurology.
Then see above under coursework.
________________________________________________________________________________
As much exposure to patients as you can muster. Follow
a resident on call.
________________________________________________________________________________
Again, I think it is a good basic knowledge of the
fundamentals. That is why I think the double helix
program is good
as you go back to some of the basic sciences in
the third and, eventually,
in the fourth year.
(back to top)
Chapter 6: Neurology Programs: Top Picks by Current Faculty
and Residents
For the most part, my comments will necessarily
be limited to institutions where I have interviewed or where
I have acquaintances
who can give me reliable information.
I know this may sound really hokey, but I swear it’s
my honest opinion right now: I would very strongly consider
the
U of R as a top choice! This program, like all programs, has
its strengths and its weaknesses, but overall I think the training
is quite good. I have been impressed with the residents with
whom I have interacted. I know Dr. Jozefowicz and have a great
deal of respect for him, and I know that he takes the needs
of the residents seriously. When problems arise, it appears
to me
that he tries earnestly to reach a fair solution.
Indiana University in Indianapolis would be another good choice.
I interviewed there in 1997 and was very impressed with the program.
They seem to have good balance overall, though I did get the
sense that the residents might have been overworked.
The University of Cincinnati has a small but very solid program.
I did not interview at Wake Forest or UNC-Chapel Hill but I
trained with residents who did their medical school and internships
there. My impression is that both have very strong programs.
The Mayo Clinic (Rochester) has a very strong program with good
training, but I myself found the culture a bit too formal for
my tastes.
Vanderbilt seemed quite good when I interviewed there, and I
think one would get very good training there.
Emory in Atlanta has a very strong program, but I understand
that the residents are very, very busy.
The University of Florida at Gainesville is also good, but I
would worry that there might not be enough of a balance in the
program. Cognition and Behavior is so strong there it might overshadow
other areas.
________________________________________________________________________________
I’m a midwesterner so I am biased in that respect. You
will see most people here are East coast biased. The important
thing to remember is that really good neurology programs are
difficult to find. I still think the top five programs are:
Rochester, Mayo Clinic, Cleveland clinic, Michigan, Virginia
(That was the order of my rank list). I think others that are
very good include Indiana, Utah (definitely worth checking
out), Wake Forest, Penn, and Columbia. I think it is good to
get a lot of opinions on this because many people feel differently.
I think you find a program you know is good then you decide
if you want to live there.
________________________________________________________________________________
UR - I could have gone to many in the Northeast (where I
would like to be for family reasons), but I still would choose
here.
________________________________________________________________________________
I do not know the programs now well enough to comment in
depth. I like U of R. I also liked Michigan which has good
qualities
in a similar vein.
________________________________________________________________________________
My top 5 were as follows: University of Rochester, University
of Michigan, Mayo clinic, University of Iowa, University
of Virginia. I specifically wanted to stay out of the big
cities
so that this was a priority for me. There are excellent programs
in SF, Boston, Philly, etc., so ask about them. The programs
I chose were medium sized, had diverse faculty, had a good
variety of patients with a good referral area and I liked
the residents.
________________________________________________________________________________
Top choices: Columbia, UR, UPenn (great program, good faculty,
good exposure to both everyday and esoterica), UCSF (what’s
not to like about San Francisco), Duke, University of Chicago,
Mass General, Cornell. You may notice that I didn’t put
down the Mayo Clinic. Others would disagree. My feeling is
that it is a great place for neurology, but not necessarily
residency training. Not enough bread and butter neuro to balance
the rare entities; a somewhat unreal environment.
________________________________________________________________________________
I personally think the program at the University of Rochester
is excellent. The University of Iowa is also an excellent
program. However, there are many good programs scattered
throughout
the country. I think that anyone going out to look at residencies
has an embarrassment of riches, as you probably can’t
make a mistake with any of the better programs. It is important
to talk to the residents in training at that program and see
what they think of it. Also, you have to be aware of any program
that does not fill the number of spots.
(back to top)
Chapter 7: Other Advice
Please offer any other advice to medical students:
