Education Research: Bridging the Undergraduate Neurosciences With Clinical Neurology Neuroscience

There is a signi ﬁ cant shortage of neurologists in the United States, and this shortage is projected to worsen considerably. With the growth of undergraduate neuroscience majors, there may be opportunities to engage and motivate undergraduate students interested in the neurosciences toward clinical neurology. We surveyed undergraduate neuroscience faculty to better understand their curricular goals, existing interaction with neurologists, and their desire for additional connections with clinical neurologists and clinical neurology researchers. We invited 523 undergraduate neuroscience faculty (members of Faculty for Undergraduate Neuroscience) to complete an online survey assessing their research areas, courses taught, existing professional networks, and interest in developing connections in clinical neurology/neurology research. We had 140 of the 523 neuroscience faculty (26.8%) complete the survey. Of the 140 respondents, most respondents (93.6%, 131/140) stated their courses included a discussion about neurologic conditions, yet only 4% (6/139) stated addressing the shortage of neurologists in the country. Few reported they were able to partake in professional development opportunities for shadowing neurologists, neurosurgeons, or similar specialists prior to teaching neuroscience courses (19%, 26/140). Understanding neuroscience faculty ’ s perspectives on how to bridge undergraduate neuroscience programs and the ﬁ eld of neurology is critical. This way, we can identify potential gaps and make recommendations for how to improve the neurology pipeline.

There is a shortage of neurologists in the United States, and the projected shortage is expected to significantly worsen in the years to come.In 2021, fewer than 800 graduating allopathic or osteopathic medical students in the United States applied for postgraduate year 1 (PGY1) residency positions in neurology and only 702 PGY1 residency positions in neurology were filled. 1 By contrast, an additional 21,400 neurologists are thought to be needed by 2025, leading to a shortfall of at least 18%. 2 Thus, although most neurology residency positions go filled each year, there are too few residency positions to fill the anticipated shortfall of clinicians. 2 To improve the pipeline, it is necessary to understand where barriers exist in the neurology pipeline and how these might be overcome.
Recent research has shown that barriers exist in the neurology pipeline in the undergraduate/baccalaureate years.Neurology is not as visible or widely considered as a career path by undergraduate students, 3,4 although the neuroscience major is the fifth most common undergraduate major for medical students. 5In fact, nearly 20% of neuroscience majors apply to medical school, 4 yet most do not become neurologists.Being a neuroscience major in the undergraduate years increases the likelihood of pursuing a career in neurology; at the time of medical school graduation, 13.3% of those entering neurology were neuroscience majors in undergrad compared with 4.5% of those not entering neurology. 6Thus, despite the recent growth in neuroscience programs at the undergraduate level from fewer than 10 programs and fewer than 100 graduates in 1986 7 to over 200 programs with over 7,000 graduates in 2018, 8 and the connection between majoring in neuroscience and pursuing neurology, neurology is only considered as a future specialty by only 2.7% of students entering medical school. 4recent study of undergraduate students interested in the neurosciences from across the United States and from 40+ undergraduate institutions reported very high levels of interest in gaining clinical neurology experience (4.66 ± 0.74), shadowing a neurologist (4.69 ± 0.76), working with neurologic patient populations (4.69 ± 0.68), and doing clinical research (4.56 ± 0.81) (all measured using Likert Scale 1-5). 9wo-thirds (66.7%) reported interest in conducting patientcentered clinical research.Most students (87.3%) also indicated interest in attending neurology conferences.Despite these reported interests, few students were able to have these experiences.For example, less than one-third (28.8%) had spoken with neurologists about career experience, but 95.5% of those who had the opportunity to speak with a neurologist reported that the interaction was helpful in learning about the career.Despite high interest in clinical neurology exposure, less than one-third of students had spoken with or shadowed a neurologist and only 13.6% had interacted with clinical neurology populations.Only 20.8% of students felt volunteer, and internship opportunities were sufficiently available.
With the growth in neuroscience majors at institutions across the country, an opportunity exists to develop appropriate curricula, training, mentoring, and research experiences to introduce the field of neurology and to enhance exposure to the field of neurology.Faculty who teach undergraduate neuroscience play the most important role in designing the curriculum and content disseminated in their courses.They frequently serve as faculty mentors to undergraduate premedical students, write letters of recommendation to students apply to medical school, and may serve on medical school application review committees.Gaining exposure to clinical neurology at this critical time in a person's academic path could have a significant effect on career choice.In this study, we surveyed undergraduate neuroscience faculty to better understand their curricular goals, existing interaction with neurologists, and their desire for additional connections with clinical neurologists and clinical neurology researchers.

Methods
We conducted a cross-sectional survey of the members of the Faculty for Undergraduate Neuroscience (FUN), 10 a professional organization dedicated to neuroscience teaching and research established in 1991. 10FUN focuses on promoting neuroscience undergraduate research opportunities and education.

Survey Instrument Development
The survey was first developed and modified by a clinical neurology-researcher (M.T.M.) and undergraduate students on the team (S.A., M.E.-P., D.K., J.G., K.K.) through 2-3 collaborative sessions.Then, the survey was iteratively reviewed and revised by faculty members of FUN and the American Academy of Neurology Insights Team (full survey in eAppendix 1, links.lww.com/NXG/A543).

Survey Distribution
The official website of FUN has a list of all faculty members (523 undergraduate neuroscience faculty).An email was sent inviting them to complete an anonymous online survey in research electronic data capture (REDCap) 11  professional networks, and interest in developing contacts in clinical neurology/clinical neurology research.After the initial survey invitations were emailed, reminders to complete the survey were posted on the FUN listserv and REDCap sent out autoreminder emails.Participants had 21 days to complete survey responses.

Compensation
Participants received American Academy of Neurology (AAN) letters of recognition and access to a website with a compilation of helpful resources (e.g., upcoming conferences, internship opportunities, and journal names) for undergraduate students interested in neuroscience and clinical neurology.

Data Analysis
The quantitative data from survey responses were analyzed in version 16.44 of Microsoft Excel, and the qualitative data was coded using grounded theory by 2 researchers on the team. 12andard Protocol Approvals, Registrations, and Patient Consents This study was conducted with approval from the NYU Langone Institutional Review Board.The board waived the need for informed consent.

Data Availability
Anonymized data not published within this article will be made available by request from any qualified investigator.

Characteristics of Neuroscience Programs in the United States
Most respondents indicated that their institution offered a neuroscience major (61%, 86/140), with some also offering a neuroscience minor (45%, 63/140).As shown in Figure , D, of those that offered students the opportunity to major in neuroscience, many require either a capstone project (41%, 35/ 86) or a senior thesis (21%, 18/86).For their capstone/thesis requirements, neuroscience major students were allowed to

Perceptions of Neurology Research
To better understand faculty references to clinical neurology in their courses, respondents were asked to define "clinical neurology research" in the form of a free text response (Table 2).Four main themes emerged.In the first theme titled "Research of healthy humans and clinical populations," faculty gave responses that focused on doing research of clinical populations such as "Research with humans with various neurological conditions" or "Deficits resulting from any abnormality in the brain."There were also responses that focused on defining neurology as research of the "Brainbehavior relationship."The second theme titled "Research on the nervous system" contained any response that mentioned the key words "nervous system."The third theme titled "Collection of data for diagnostic or treatment application" contained responses that saw clinical neurology as a means to develop "treatments," "diagnostic criteria," or "medical application."An example of an answer in this theme is "Research that has a more direct application to yielding medical treatments than research that is intended to help with understanding the healthy nervous system."The fourth theme titled "Research on diverse subfields of neuroscience" contained responses that used neuroscience within it and referred to various subfields of it including topics related "translational neurobiology" or "epidemiology" or "neuroradiology."Of note, 5 of the 123 respondents indicated not knowing how to define clinical neurology.(3) regional limitations; and (4) student interest, experience, and discomfort (Table 3).The first theme "lack of exposure" was based on a lack of connections as reflected in the following responses: "connections necessary, don't know one" or "connections, we're a small school and we just don't have someone who can do the leg-work for us."The second theme "inadequate resources" contained responses related to financial hardship/time constraints and funding limitations, which can be exemplified in this response "students need money to live on if they are to have a significant experience."

Current Opportunities
The second theme also emphasized the few opportunities available, including the competitiveness of getting opportunities as a barrier as well as the fact that researchers and physicians are often unwilling as they do not want "undergraduates in their labs" or do not "provide opportunities."The third theme "regional limitations" included responses that mentioned geography as being a barrier like "our campus is too distant from a clinical setting.

Discussion
This study gains insight from undergraduate neuroscience faculty who teach students about the brain and who may be the first to expose these students to neurology.Our results show that despite increases in the number of institutions offering an undergraduate neuroscience major or minor in recent years, there are currently several key barriers limiting the ability to connect the undergraduate neurosciences to clinical neurology, including faculty being neutral (not comfortable or very comfortable) regarding their familiarity/comfort with clinical neurology, lack of curricular exposure to clinical neurology, and limited resources to share with students.Undergraduate neuroscience programs could prioritize discussion of neurology/clinical neurology clerkships and electives within medical school, along with initiatives that further connect the clinical neurology and neuroscience education communities.This will likely result in an increased awareness and interest among this student population and take advantage of a time when students can make academic decisions that lead to a future career in neurology.
Neuroscience faculty do not feel comfortable with clinical neurology concepts.Thus, initiatives that grow the clinical knowledge base of neuroscience faculty may translate into greater comfort and familiarity as well as inclusion of this content into the classroom.For example, the AAN might develop an online instructional material for faculty which could then be used in their courses.A consequence of the aforementioned barrier, the lack of faculty knowledge base about clinical neurology, is that a valuable clinical neurology material may not be incorporated by these educators into their course materials.Our findings are also supported by prior findings that unfortunately, few undergraduate neuroscience majors are exposed to clinical neurology and clinical neurology research opportunities because the curricular focus is most heavily on the basic science. 13The undergraduate years are a period when students often want to learn about careers applicable to their studies.Undergraduate students have expressed increased awareness of issues in medicine.Learning about the clinical application of the undergraduate work can have a profound effect on their career choice. 14Our results indicate that neuroscience students could be made more aware of the current shortage of neurologists in the United States and that a career in neurology could be a good fit for students interested in the brain and brain research.Currently, only 4% (6/139) of faculty initiate discussions about the present-day shortage of neurologists in the United States, and only 39.9% (55/138) teach students about translational neuroscience research.Discussion of both of these topics is key to greater understanding among neuroscience majors of career opportunities that exist for them.In addition to a general deficit in the number of neurologists in the United States today, there exists an even greater demand for underrepresented neurologists and neurology researchers. 15Our survey revealed that only about half (51%) of faculty members speak frequently about possible career options in the field of neurology.Thus, undergraduate neuroscience majors represent a student population for targeted outreach prior to medical school.
To increase representation and engage with diverse groups of neuroscience students, there needs to be strategic outreach, an increase in the availability of campus or classroom discussions about the present-day scarcity of neurologists, and more frequent discussions about the clinical neurology careers available to neuroscience majors.Developing courses that include neurologists as guest speakers, opportunities for students to meet people with neurologic conditions, and opportunities to discuss neurology cases might be ideal.Future work might also compare the experiences of undergraduate neuroscience faculty and students at institutions with and without an affiliated medical school to determine whether they might have different abilities and needs in establishing the clinical and research opportunities in neurology.In addition, it may be beneficial to have pipeline initiatives that help faculty who mentor premedical students by providing resources on mentorship on how to get into medical school, how to write letters of recommendation, etc.
there was widespread geographic distribution of respondents' colleges, generalizability of our study may be limited by our response rate of 26%.2][23] In addition, most of our respondents (65%) were from Liberal Arts colleges.Those from private research universities comprised 17% of our sample.This may present a bias in respondents in saying students need more funding and research opportunities.In addition, we do not have demographic information on the nonresponders.This may limit some of the generalizability of our conclusions.
Neuroscience faculty are interested in exposing students to the field of neurology.Despite discussion of neurologic conditions in courses, there is an absence of emphasizing the need for neurologists in the United States.Undergraduate neuroscience can likely be bridged with clinical neurology by enhancing neurology shadowing, research experiences, as well as connections made in the classroom (in-person or remote).Based on this study, we suggest the development of resources to (1) increase faculty comfort with neurology, (2) enable students to network and develop relationships with neurologists and have hands-on neurology exposure, and (3) help students find sources of funding for such programs.Resources need to be available to faculty and their respective students in different geographical locations online or by providing funding for travel.Finally, participation in these programs should count toward capstone or major requirements to promote undergraduates to pursue these opportunities.

Table 3
presents opportunities for students in clinical neurology or clinical neurology research.Faculty respondents indicated that current opportunities for students in clinical neurology or clinical neurology research include shadowing a neurologist/clinical work in a neurology setting (75.8%, 75/ 99), research positions within an academic medical center Figure Distribution of Institutions, Faculty Courses/Research, and Undergraduate Research Requirements *Patient-centered research focuses on patients' beliefs, preferences, and needs, in contrast to clinical neurology research which focuses on the scientific study of fundamental mechanisms that underlie diseases and disorders of the brain and CNS.(80.8% 80/99), and volunteering with patients with neurologic disorders (55.6%, 55/99).In addition, 24.6% (34/138) reported inviting practicing neurologists or clinical neuroscientists to visit and speak to students about their work.Of those who did not currently invite such speakers (N = 103), nearly all (99%, 102/103) were in favor of having the opportunity to do so in the future.Some faculty indicated that research opportunities were available at their institution on a student-to-student basis (91.7%, 22/24), but very few (20%, 6/30) reported that their department/program had a formal research program in place with neurologists.Most (89.3%, 25/28) faculty noted that shadowing opportunities were available to students on a case-by-case basis, but very few (24.3%, 9/37) reported that their department/program had a formal shadowing program in place with neurologists.Similarly, few faculty (28.1%, 39/139) indicated having connections with nearby neurologists for students to have a clinical neurology shadowing opportunity.Barriers for Students Toward Finding Research OpportunitiesFour major themes emerged from faculty's responses to the question "What have you noticed as the main barriers for your students towards finding clinical neurology research opportunities?"They were (1) lack of exposure; (2) inadequate resources;

Table 3
Existing Opportunities for Students in Clinical Neurology or Clinical Neurology Research 19 the lack of practicing neurologists as faculty mentors, inability to access patient populations or inadequate funding.Establishing connections between practitioners and institutions with neuroscience programs is a direct way to open clinical research opportunities for students.An additional important limitation reported by faculty members was the lack of a formal program in place for students looking to pursue research opportunities in neurology.Multiple studies have shown that direct hands-on experience is an important factor in career choice, and one of the most important factors in graduate school admission is students' research experience.19Infact, a 2019 report generated by the Association of American Medical Colleges, after surveying medical school admissions faculty on the factors that are of importance when offering interviews/acceptance offers, found that on a scale of 1-4, research experience was rated as ≥2.5 and <3.0.20 While opportunities for involvement in basic neuroscience research are abundant through faculty laboratories on campus or as part of thesis/capstone requirements, there are significantly fewer opportunities for engaging in clinical neurology research or patient-centered research.This may be due to an inability to access formal/informal clinical neurology research or shadowing opportunities because of the geographical location.For example, not all colleges have a medical school or large enough medical center nearby with practicing neurologists.Similarly, some campuses lack professors who are practicing clinical neurologists or research laboratories engaged in clinical neurology research.In addition, when clinical neurology research opportunities are present on campuses, they are reportedly highly competitive, and the availability of undergraduate positions is far less than the demand from students.In other cases, undergraduate students are not desired in clinical neurology research laboratories and time is spent engaging graduate students in faculty research.With the idea of creating more formal programs, there could be opportunities that are performed online or summer opportunities with possible housing or stipends for students to experience working with neurologists in a hospital or research setting.neurologists in their area.Future work might build on the recent publication which discussed how various clinician neurologists and clinician neurology researchers have integrated undergraduate students into their work.Only 20% (6/30) of faculty who reported having research programs in place for students indicated having a program specifically for neurology, and many had no programs in place at all.Funding, a shortage of networking and clinical and research opportunities in neurology, and a lack of formalized neurology programs for students are the 3 most important barriers; addressing this may go a long way to reducing the shortage of future neurologists in the country.
thesis requirements.The reasons for this distinction and the logistical or departmental impediments students face in pursuing clinical neurology research for their culminating undergraduate research projects are important areas for further research.An initial prediction as to why colleges may discourage or prevent students from pursuing clinical neurology research projects, based on faculty's perceived barriers for students, mayBased on this study, future steps to increase students' interest and likelihood of pursuing a career in neurology should include creating formal undergraduate programs that provide students with funding, research, and networking opportunities with