Education Research: Appraisal of Outpatient Clinical Experience During Neurology Residency

Discussion

In this study of outpatient resident experience during postgraduate training in the United States, a cohort of 5 neurology residents of the same class encountered a variety of neurologic diseases and symptoms in their continuity clinics. However, more than half of the clinical workload was constituted by just 3 neurologic disorders: headache, neuromuscular, and movement disorders. This salient finding is congruent with the natural history of these particular neurologic disorders, which rarely require inpatient management. It is of more interest that the clinical experience of residents in the outpatient setting appears to be noticeably distinct from the inpatient setting. Headache, neuromuscular, and movement disorders, which accounted for 54% of the outpatient diagnosis in our study, made up only 14%–17% of all diagnoses in previously published inpatient focused studies.^3,4 On the contrary, cerebrovascular disorders and epilepsy, the most commonly encountered diseases evaluated by residents in the inpatient setting, comprised 19% of outpatient diagnoses in our study (Table 3). This contrast of case mix supports the common notion that outpatient and inpatient clinical experiences of neurologists (including trainees) are relatively different. Although certain neurologic disorders such as cerebrovascular disorders and epilepsy are likely to encountered with similar frequency in either setting, others, such as movement, headache, and neuromuscular disorders are near exclusively encountered in the outpatient setting. This finding demonstrates that a resident's outpatient experience is not just a replication of inpatient experience but adds to it in a significant manner. Similar to our results, a survey of 24 outpatient neurology practices in Colorado found neuromuscular and headaches disorders to be the most common neurologic disorder diagnosed in the clinic.⁶ This suggests that the range of outpatient clinical experience during residency mirrors real-life practice of neurology. Over the course of residency, we found that the number of cerebrovascular and neuromuscular disorders encountered by the cohort decreased. However, it increased for all other neurologic disorders. We speculate this may be because the long-term care of these disorders was taken over by primary care providers after they were diagnosed and initially managed in a neurology clinic.

Residency training primarily occurs in the inpatient setting, which is in contrast with general neurology practice, which tends to be primarily based in the office setting.^2,6 Only 6 months of outpatient experience during 36 months of residency is mandated according to current requirements.¹ The continuity clinic forms the core of this outpatient experience, with a minimum of 40 half-day clinics required per year throughout residency.¹ Resident and program director surveys have expressed a desire to increase the amount of time spent in the outpatient training,^7,-,10 perhaps reflecting the differences between general neurology practice and neurology training. However, there are several challenges in restructuring neurology residency programs, including an increased focus on revenue generation and not teaching, growth of inpatient neurology service lines leading to pressure on time spent in the outpatient setting, and the need for direct supervision of trainees by faculty.¹¹ Obtaining robust data that demonstrate the value of outpatient education in neurology education can overcome some of these barriers.

We used administrative health data to gauge resident clinical experience in the outpatient setting. These type of data have been used successfully in the epidemiologic study of diseases,¹² and they have been validated in the study of neurologic disorders.^13,-,15 It allows a thorough assessment of resident's clinical experience by capturing the diagnoses and symptoms evaluated during patient encounters. Unlike previous studies,^3,4,16 which only analyzed NPVs, we analyzed both new and RPVs to assess the longitudinal experience of residents—the core goal of continuity clinic. Furthermore, we analyzed all neurologic diagnoses associated with a patient visit rather than focusing on the principal diagnosis or chief complaint. It is not uncommon for patients to experience comorbid neurologic disorders; a patient with a remote history of ischemic stroke who develops focal epilepsy and a patient with generalized epilepsy with comorbid migraine. Managing multiple neurologic disorders in a patient contributes to a trainee's experience and should be reflected in any such assessment. To obtain meaningful information from the data set, and when possible, we grouped diagnoses and symptoms into categories. When possible, we grouped neurologic diagnoses according to categories outlined in the ACGME milestones project during the study.⁵ Neurologic symptoms were grouped anatomically or according to sensory domain affected. For example, visual symptoms consisted of ICD codes for diplopia, vision loss, decreased vision, and anisocoria. The approach of grouping diagnoses and symptoms may have compensated for the variability among residents in choosing the ICD code for a given complaint; for example, a patient reporting tingling and numbness in the feet can be coded as “paresthesia,” “anesthesia,” and “disturbances of skin sensation,” but enumerating it as a sensory symptom overcomes the differences. We assigned specific diagnoses such as migraine, migraine with aura, migraine without aura, and other primary headache disorders (ICD codes G43, G44) to the neurologic diagnosis category. However, ICD code for headache (R51) was placed in the symptom category. Similarly, we placed epilepsy—focal or generalized (ICD G40), in the diagnosis category, whereas unspecified convulsions (R56.9), was placed in the symptom category. We acknowledge that this system was somewhat arbitrary and may have led to overcounting or undercounting diagnoses and symptoms.

This study has at least 6 major limitations. First, we might have overestimated the neurologic diagnoses and symptoms prevalent in the continuity clinic as we enumerated ICD codes across multiple visits (NPV and RPV) for a patient. On the contrary, there could be an undercount of diagnoses and symptoms because of the onerous nature of the ICD system because residents may not have entered all the pertinent ICD codes relevant to an encounter. This may particularly be the case in the early part of residency. Because only 1 ICD code is required to close and bill a patient encounter, there is no incentive to enter other diagnosis or symptom codes. Furthermore, the role of supervising attending in choosing ICD codes for each encounter was not specifically addressed in our study, and it may have made an impact on the results. Second, this is retrospective study from 1 residency program, and it does not account for interinstitutional differences in disease prevalence, clinic location (urban vs rural), availability of subspecialists in the department, and the presence of other learners (fellows), all of which may affect resident experience. Third, this study evaluated 1 portion of the resident's outpatient experience because in most programs, including ours, residents gain significant skill and knowledge during their subspecialty clinic rotations. Fourth, we did not directly compare the inpatient and outpatient experience of the same set of residents. Fifth, administrative health data have not been previously used in neurology education research. However, it has been validated in the study of other neurologic disorders.^12,-,15 Sixth, the sample size of 5 residents evaluated in this study was small. We studied just a single class of residents (from a program complement of 20) to obtain preliminary data as this topic because it has not been studied in great detail in the past. We intended to use these preliminary data to identify areas of improvement in our program and implement changes to our outpatient resident experience. We are currently collecting data prospectively from a larger cohort of residents in our program. Despite these limitations, this study provides first insights into the outpatient experience of neurology trainees during residency and adding to the limited literature on the topic. Unlike previous studies from the United States, which reported single trainee experience from urban academic centers, we report the experience of a cohort of 5 residents of the same class from a program, which primarily serves a rural population.

We found that continuity clinic experience for the residents may have been diverse, but the total number of patients evaluated by each resident over the course of training may not be adequate to prepare them for independent practice. Furthermore, we found that certain neurologic disorders tend to be referred to subspecialty clinics (neuro-oncology, sleep neurology) rather than to the pool of continuity clinic. In response to these findings, we made changes to our program's outpatient curriculum and structure. The major change was introduction of a mandatory outpatient rotation called the subspecialty clinic rotation. During this rotation, residents get an opportunity to evaluate new and return patients while working with various neurology subspecialists for 2 months every year (PGY-2–PGY-4). The schedule for this rotation is made by the program director to ensure relative equity and diversity of clinical exposure. We are currently gathering data from this rotation to determine objectively whether the changes implemented broadened resident's clinical exposure to neurologic disorders in the outpatient setting.

We also made other changes to our program's outpatient training structure based on the results of this preliminary study, which are ongoing. Currently, we are collecting data prospectively from a larger pool of residents in an attempt to improve the quality of data. At the same time, this would allow us to monitor residents' clinical experience as they advance through training. We are also obtaining data from community neurology practices affiliated with our department to compare the disease mix encountered in a general neurology practice with that of our trainees. Please see Table 4 for a summary of changes to our program based on the results of this study.

There are several knowledge gaps in the subject of resident education and training in the outpatient setting. First, the relative value of inpatient and outpatient training in preparing residents for independent neurology practice is unknown. Future studies comparing resident experience in the inpatient and outpatient settings in the same program during the course of residency may help answer this. Of interest, teaching medical students about neurology in the ambulatory setting compared with inpatient setting was found to be effective.¹⁷ Second, within the outpatient setting, the educational value of continuity clinics and subspecialty clinics has not been evaluated separately. Third, differences and similarities in clinical experience among residents at the same level of training within and across residency programs has not been evaluated. Our data hint at interresident variability; however, these preliminary findings need to be explored further. We suggest that research studies that collect data prospectively across multiple residency programs can fill some of these knowledge gaps.

Beyond its positive impact on resident experience, educational research in the outpatient clinic offers opportunities for quality improvement. For instance, the ambulatory experience of residents considering fellowships that are primarily based in the outpatient setting (e.g., movement disorders, neuromuscular medicine) can be improvised; thus, these residents evaluate patients with such disorders early in their training (PGY-2), so they can explore their interests well before fellowship applications are due. Another potential quality improvement intervention could be longitudinally monitoring trainee progress in the outpatient setting, including diversity, and extracting the most educational value out of it. Residents who are lagging behind their peers in the evaluation and management of certain neurologic diseases can benefit from more patient encounters pertaining to these disorders. Furthermore, educational research in the outpatient setting can inform decisions about restructuring neurology training such that it is in sync with the requirements of modern neurology practice.

During the course of their residency, 5 neurology residents evaluated a wide range of neurologic disorders in their continuity clinics with headache, neuromuscular, and movement disorders making up half of their workload. This clinical experience appears to be different from previous reports of resident experience in the inpatient setting. We implemented changes to our program's outpatient curriculum based on the results of this study with the aim of improving the quality of residents' outpatient exposure during training and supplementing their continuity clinic experience. There is a need to further evaluate the clinical and educational experience of neurology residents in the outpatient setting.