Keyword:
Forecasting - Neurologists - Teaching - Mentoring - History, 21st Century - Humanism
- Clinical-Anatomic Correlation
Palavras-chave:
Previsões - Neurologistas - Ensino - Tutoria - História, Século XXI - Humanismo -
Correlação Anátomo-Clínica
INTRODUCTION
The training of neurologist for the future is a challenge due to discoveries that
certainly will change much of our knowledge on diagnosis and treatment of neurological
diseases. Predicting what will happen in the future in any area of medical knowledge
is practically impossible, because “progress largely depends on discovery, and discovery
cannot be predicted”[1]. In its March 1949 edition, Popular Mechanics, a well-known magazine, predicted:
Where a calculator like the ENIAC today is equipped with 18,000 vacuum tubes and weighs
30 tons, computers in the future may have only 1,000 vacuum tubes and perhaps weigh
only 1½ tons
[2].
The best neurologists of the early 1970s, when I started my residency in neurology,
could not predict the impact on neurology of information technology, neuroimaging
techniques and genetics.
In this sense, our forerunners were much more conservative than we are now when thinking
about the very near future. We are now seeing so many changes in just a few months
due to technology that it is common to hear that “we just don’t know where these new
machines (mainly related to information technology) are going to take us”.
Although it is not easy to understand that in the next 50 years we can make progress
as great as was achieved in the previous 50 years, most likely the advance will be
even greater, as it has been over time. How to prepare the neurologist for these new
times? This is a huge challenge, but as a starting point we can use the fact that
we must work with a less broad perspective, that we will have to prepare the neurologist
for the very near future and not for the more distant, as this is almost completely
intangible.
In 2015, Professor Vladimir Hachinski organized a session at the World Congress of
Neurology to be held in Santiago, Chile, and invited Morris Freedman and me to share
with him the themes he proposed. For me, the suggested theme was: Constants in a changing world (what should remain in the neurology of the future). This perspective is also of
interest for this presentation and is the one I shall use the most - always thinking
about the very near future. The Department of Neurology of the Medical School of the
University of São Paulo, located at Hospital das Clínicas (DN-USP), where I did my
residency in neurology and spent my entire academic career will always be my model
for criticism and proposals.
According to Abraham Lincoln, “The best way to predict the future is to create it”[3]. Or as Hachinski (2002)[1] wrote: “However, understanding from where we are coming may help guide where we
are going”. This is the task that will fall to all those who participate in the training
of new neurologists.
Within our limitations, we can think about what kind of doctor the neurologist of
the future should be. Which qualifications should neurologists have? And from there,
we can imagine a broad, but at the same time flexible curriculum.
THE IMPORTANCE OF NEUROLOGY IN THE FUTURE
THE IMPORTANCE OF NEUROLOGY IN THE FUTURE
Neurological diseases are the world's largest cause of disability-adjusted life years
(DALYs), or years of a healthy life that are lost to due to death or disability. Neurological
disorders caused 9.4 million deaths in 2015, up 36.7 percent from 1990, making them
the second leading cause of mortality across the world after cardiovascular disorders[4].
Due to the aging of the world population, advances in diagnosis due to neuroimaging,
genomics, increasing knowledge in neurosciences and far more available treatments
for neurological diseases, neurology is going to be a much more important area of
medicine than it is today.
In 2021, the American Academy of Neurology stated that there were 31 neurology fellowship
areas, of which 17 are already accredited while 14 are not yet accredited[5]. Neurology is a large area of medicine with many sub-specialties yet to be developed.
But there is a central nucleus for the neurologist's initial training, which is common
to all who are to dedicate themselves to each of these sub-specialties.
PROFESSIONAL SKILLS
The central core of the training of a neurologist has been that of topographic diagnosis:
the clinical/anatomical correlation. Clinical diagnosis in neurology requires several
steps: 1) Recognition of impaired function; 2) Identification of what site or sites
of the nervous system has been affected (localization); 3) Differential diagnosis
of the cause; 4) Use of ancillary testing to diagnose the disease[6].
But neurology needs to go far beyond diagnosis, and it has. In this sense, it is worth
discussing what role is expected of the neurologist in medical care in general.
A CONSULTANT FOR DIFFICULT CASES WITH NEUROLOGICAL DISORDERS?
A CONSULTANT FOR DIFFICULT CASES WITH NEUROLOGICAL DISORDERS?
Should the future neurologist be prepared to be a consultant, who will help other
specialists in the diagnosis of neurological diseases and the neurological complications
of systemic diseases? With the advancement of neuroimaging techniques, diagnostic
methods with biomarkers in cerebrospinal fluid (CSF) and plasma, with genetic diagnostic
techniques, it will be very difficult for the non-neurologist to analyze and assess
the importance of all the data acquired from a patient. A neurologist will be needed
to verify the importance of a neuroimaging finding, a concentration of a biomarker
or a mutation of uncertain value. We can imagine that this role of the neurologist
as a consultant will grow. But this must not be the only or the most important role
of the neurologist of the future[7].
Comprehensive Care: the neurologist as the primary physician to diagnose, treat and
follow up the patient with neurological disorders?
There are several reasons for supporting the understanding that the neurologist should
be the primary physician in neurological diseases. This may take place as an office
neurologist in outpatient clinics or in hospitals, including intensive care units.
To be the primary physician the neurologist should also receive training in clinical
medicine and psychiatry during the residency program[7].
There is in addition another role, which is going to be shown later: the neurologist
as clinical neuroscientist.
PREPARING THE FUTURE NEUROLOGIST
PREPARING THE FUTURE NEUROLOGIST
This session should answer three main questions: Who should teach them? What should
they learn? How to teach them?
Who should teach?
During the residency program, neurology should be learned mainly from neurologists.
In the DN-USP, we believe that young former residents (preceptors) are the best for
teaching neurology for residents (this has been the method of teaching neurology in
our department for more than 50 years). The preceptor is selected among the residents
who have just completed the residency program, primarily by their peers, who should
evaluate qualities of knowledge, didactics, leadership, and ease of interpersonal
relationships. The choice is usually confirmed by the heads of the service.
We currently have two preceptors who are the main trainers of new neurologists, teaching
how to take the medical history and perform the neurological examination at the bedside,
and discussing cases in small groups. Each year, new preceptors replace the previous
ones and try to do their best to be even better than those who preceded them. This
method, although old, works very well and should be implemented using online meetings.
There are also rounds with the members of the clinical neurologist’s staff. Lectures,
rounds and meetings with the clinical neurologist’s staff and other important teachers:
neuroimaging specialists, neurophysiologists and neuropathologists. In the future,
hybrid meetings, partially face-to-face and partially online will predominate.
What should the future neurologists learn?
In the teaching of neurology, the initial step is the learning of neuroanatomy. Without
this knowledge, it is not possible to progress in the specialty.
Neuroanatomy in the context of neurology is the best way to teach and to win this
challenge. That is why neurologists may be very good teachers of neuroanatomy for
future neurologists. When an anatomical structure is linked to a function or to a
sign caused by its lesion, the learning of neuroanatomy becomes much more interesting
and easier for the future neurologist
There are new methods and, for sure, further new methods will be available. Students
who took the course with 3D computer-based learning of neuroanatomy achieved better
results than those who took the course in an anatomy laboratory[8]. A neuroanatomy teaching method using a smartphone proved to be more efficient than
a study carried out with books on anatomy[9].
Correlation with neuroimaging methods and access to an anatomy laboratory will continue
to be important.
Learning how to take the history
Neurological assessment begins with a very detailed history of all symptoms and signs
and their chronology and is usually what contributes most to a diagnosis. According
to Jerome Posner (2013), “Different from all other medical specialties, save perhaps
psychiatry, the neurologist is heavily dependent on listening to and interpreting
what the patient tells us… If you don’t know what is happening by the time you get
to the feet you are in real trouble” (quoted by Nichol & Appleton, 2015)[10].
Earlier neurologists took it for granted that “If at the end of taking the history,
you do not have a likely diagnosis, take the history again”[11].
The history remains the most important part of the diagnosis and will likely continue
to be. Patients often want us to use examinations and even get anxious when we want
to know more about the symptoms, when and how they occur and if they interfere with
everyday activities. In addition to helping us a lot in diagnosis, history establishes
the first human bond between doctor and patient. We learn a little about who our patient
is, what he does, what he likes, and the more we can do to get to know him, the better
for the future treatment. This is the first P of the three Ps of medicine that we
want for the future: Personalized medicine. Others are Preventive and Predictive medicine, to which Participatory and Purpose-driven medicine were later introduced[12].
Neurological examination
Neurological examination should always be taught with the clear purpose of allowing
clinical/topographic correlation or to allow phenomenological interpretation of the
signs, as in the examination of a patient with aphasia or in Balint's syndrome. As
Aminoff wrote, “It is up to the present generation of neurologists to ensure by their
teaching and example that the skills of the neurological examination are passed intact
to their successors”[13]. However, the neurological examination with technical emphasis in the search for
a sign must allow time for access to other methods of clinical/topographic correlation.
Does it still have the same value as in the past (and is it going to have the same
value in the very near future?) Does it need to be taught in all its details as the
most conservative aspiration? Does a complete neurological examination need to be
performed on all patients? The answer is “no” to all three questions.
But the neurological examination will continue to be very important. In many conditions,
such as movement disorders, vertigo, and distinguishing between signs caused by neurological
diseases or psychogenic (or functional) disorders or malingering is critical. It allows
clarification as to which ancillary tests are most needed, greatly reducing the cost
of medicine. It is also of great importance to define whether a finding of a neuroimaging
or some other test, such as a genetic study, should be valued. This is the best and
most efficient method for evaluating the evolution of most neurological diseases with
treatment[13]
-
[15].
There will not always be patients with all the important signs we would like to teach.
Face-to-face examination of patients is essential. The ability to elicit signals can
only be learned by examining. Films, videos and other similar resources should be
used and, whenever possible, resident training services should have their own resources,
made available through publications or sharing and should also use items available
in digital databases, always with care to verify the source and accuracy of the information[16].
Even a relatively short neurological examination, in which balance, gait, muscle strength,
coordination, reflexes, ocular, facial and bulbar motricity are evaluated is able
to establish a closer relationship between the neurologist and the patient. At the
end of the neurological examination, many neurologists must have heard: “Doctor, I have never been so well examined in my whole life”
This demonstration of respect for the physician is a very important achievement, which
will be reinforced at each new follow-up visit. In addition to the knowledge of neurological
diseases and their treatment, the ability to follow the evolution of signs and symptoms,
the neurological examination can make the bond with the patient even stronger, and
this starts when taking the history. This is another important reason why we should
train the neurologist to be the main doctor in diseases of the nervous system, and
not simply a consultant[7],[13].
Clinical/topographic correlation (localization of the lesion or dysfunction)
This is the essential knowledge that history, neurological examination and ancillary
examinations seek. Establishing the cause of the disease in neurology (the etiological
or nosological diagnosis) before knowing the topographic diagnosis would be equivalent
to making a diagnosis in clinical medicine without, for instance, assessing whether
the disease is affecting the kidneys, liver or heart. Imaging tests, particularly
MRI, are very helpful in topographic diagnosis, but there is a need to establish a
correlation between the neuroimaging findings and the symptoms and signs. It is common
to observe misconceptions in which multiple small areas of hypersignal on MRI in the
FLAIR acquisition, or signs of cortical atrophy typical of aging are correlated with
signs and symptoms of dementia, for example, or signs of degeneration on spinal MRI
with unrelated symptoms. Even more frequent is the misinterpretation of a correlation
with other complementary tests such as electroencephalogram and electroneuromyography.
Ancillary tests should be requested with prior knowledge of what we are looking for.
The teaching of clinical/topographic correlation is one of the most interesting to
the teacher because students of neurology know that they need to master this knowledge.
Case studies probably will continue to be the best method of teaching in the emergency
unit, wards or outpatient clinics. This should be complemented with group clinical
case discussions, in the classroom, with the presence of a senior resident, a preceptor
or a member of the clinical staff.
Nosological or etiological diagnosis
Once the topographic diagnosis is established, the steps that lead to the etiological
or nosological diagnosis are similar to those used in medicine in general, although
there are specificities in neurology, with tests that are carried out less frequently
in other specialties. This learning is mainly acquired in the care of patients in
wards and outpatient clinics of various neurological subspecialties.
Until the advent of neuroimaging, we had the history (anamnesis) and neurological
examination as our main weapons for diagnosis. Neuroimaging has largely superseded
the power of history and neurological examination for establishing the topographic
diagnosis in many conditions such as stroke, neuro-oncology and multiple sclerosis.
However in others, such as headache and epilepsy, the history remains the most important
item, while in others, such as movement disorders, a neurological examination is essential.
The diagnosis in the very near future will continue to depend heavily on the association
between clinical history, neurological examination and complementary tests, particularly
neuroimaging.
Besides the ancillary tests that are common to other specialties, neurologists need
to learn how to perform and analyze neuroimaging, electroencephalography, electroneuromyography,
CSF and ultrasound for neurovascular diseases. Currently and in the very near future,
neurologists should learn how to ask for and analyze liquid biopsies (biomarkers,
transcriptomics, proteomics)[17], results of genomics[17], and when and how to use artificial intelligence[18]. They should also learn to be aware of advances in neuroscience and its clinical
applications, and of advances in information technology (new apps, new programs).
THE NEUROLOGIST AS A NEUROSCIENTIST
THE NEUROLOGIST AS A NEUROSCIENTIST
When I started my residency in Neurology, 50 years ago, many of the diseases that
we currently diagnose were completely unknown among neurologists. And how did they
diagnose conditions such as anti-NMDAr encephalitis, semantic dementia, Lewy body
dementia, corticobasal degeneration, inclusion body myositis, and many others? They
diagnosed these as other diseases that were already known such as viral encephalitis,
Pick’s disease, senile dementia associated with Parkinson’s disease, Parkinson-plus,
polymyositis, and so on.
According to Luria (1973)[19] lesion (disease) creates a window through which we may understand how the brain
works. Or, as Miller-Fischer said, “We learn neurology stroke by stroke” (quoted by
Louis Caplan, 2020)[20].
In recent years, the number of newly-described encephalitis cases that were reclassified
after identification of genetic mutations due to clinical characterization associated
with neuroscience methods or diseases have been very high.
How were these “new” diseases or new signs for diagnosing other diseases discovered?
In many of them, the role of the clinical neurologist was the most important. It is
relevant to think that there are many “new” diseases to be discovered and treated.
A well-prepared neurologist will be able to recognize and publish a special case report
and then a case series. It will be easier if it is associated with neuroimaging, biomarkers,
genomics or other neuroscience methods. Working together with other neuroscientists
is essential, a possibility increased by the advance of online communication following
COVID-19 pandemics[21].
In the near future several new devices and neuroscience methods will be available
to improve diagnosis of old and new diseases. Considering the probable advances in
neuroimaging, we may dream of good portable neuroimaging devices, neuroimaging methods
that are less oppressive, without ferromagnetism, methods that will (almost?) reach
the refinement of the neuropathological examination (identification of acute or chronic
inflammatory reactions, identification of tumor histopathology), more neuroimaging
technologies for identifying abnormally processed proteins[17].
In the last few decades, the most important discoveries that have had an impact on
diagnosis and treatment of neurological diseases have been neuroimaging and neuroimmunology,
and more recently neurogenetics. The great challenge is the treatment of neurodegenerative
diseases. Prevention based on genomics may be the most important discovery (as in
SMA). Finally, regeneration of the nervous system seems to be a dream too far for
the very near future.
How to teach them?
Medical residency has the characteristics of “on-the-job learning”, and so it mainly
uses participatory teaching methods. Preceptors, who are the main trainers of new
neurologists in our department, teach neurological examination at the bedside and
discuss cases in small groups. We use case-based sessions focusing on clinical reasoning
and diagnostic skills, delivered to small groups, with facilitators who are skilled
and experienced in supervising team-work. With COVID-19 pandemics we have learned
to participate in online discussions with people from different centers (webinars,
meetings, collaborative study groups…)[21]. In addition we are now trying to include telemedicine in the curriculum[22] as well as the opportunity to learn and contribute to the development of digital
neurological examination[23].
In recent years, the value of each of the methods of teaching has been evaluated and
information has been widely disseminated showing that the lecture, or master class,
which has been used so much in the teaching of medicine, is one of the least efficient.
According to the so-called Learning Pyramid, lectures were efficient only for the
learning of the lecturer, but not for the students[24].
This information went in the opposite direction to the method most used in many courses,
such as the Annual Meetings of the American Academy of Neurology and the meeting we
have been organizing since 1989, named Conducts in Neurology[25]. In both, lectures or classes are the main teaching method. In both, however, there
is an important difference from the usual conferences: in addition to the lecture,
there is a syllabus or a book in which the lecture or lecturer is presented in order
to complement and maintain the information. Likewise, notes taken during the conference
can make a big difference.
The Learning Pyramid showed average information retention rates obtained with different
teaching methods. Current criticisms of the Learning Pyramid make it clear that, in
the first place, there has not been a true study that has reached these conclusions
and that there is no method that is always superior to the others, while each one
of them can be very efficient depending on the context. And finally, they point to
the teacher's role in deciding which is the most appropriate method for that learning
and its retention[24].
After the diagnosis
Despite everything we mentioned about the importance and difficulties in reaching
a nosological diagnosis, this set of procedures follows logical steps, like those
of an algorithm, which may allow for the replacement of the neurologist by artificial
intelligence methods. Or rather, the neurologist can be helped by artificial intelligence,
which will expand the training of all neurologists in reaching the correct diagnosis[18]. In the future, a professional with much less knowledge of neurology will be able
to achieve more accurate diagnoses using relatively simple data acquisition and artificial
intelligence.
During the residency program it is essential that residents develop the ability to
follow up their patients. After the diagnosis, informing the patient of the diagnosis,
with information about the prognosis and changes in life that will be necessary, the
therapeutic approaches and their constant adaptations will require the personal involvement
of the professional, which also demands training in doctor-patient attitudes.
At the forefront of the case is the patient, the human being. Empathy, understanding
what the patient and his family feel and how to reassure them, how to convey to them
the knowledge that the best treatment is being given, even when the prognosis is unfavorable,
is one of the most complex tasks for the doctor who deals with serious illnesses,
which the neurologist usually does. Empathy, the desire to know the patient, is innate
in many doctors who seek medicine out of a desire, often unspoken, to help others.
But many doctors have a more technical view of professional practice and imagine that
pharmacological or surgical therapeutic methods are the ones that really work. They
think about the case rather than about the patient. All residents must receive technical
training, but we must provide training in the doctor-patient relationship, with discussion
as to which difficulties of each patient are also discussed.
For example, the patient who lives alone suffers a huge impact from some treatments
and the follow-up may be impaired; the presence of depression, anxiety, alcoholism,
unemployment, drug addiction, among many other conditions, requires Personalized Neurology.
The human characteristic of medicine is its most important property.
In many regions of the world, people with personal, family or professional problems
look to a religious leader to talk to and get help from in making the right decisions.
Today, and probably even more so in the very near future, fewer and fewer people will
turn to religious leaders and more and more will turn to doctors for help.
The neurologist must be prepared to discuss not only the distressing issues related
to the specialty such as the risks to family members of their patients with genetic
diseases, the inexorable progression of some diseases, advance directives of wills,
the indication of palliative care, but also problems not directly related to Neurology,
but that cause anxiety, depression and anguish in the patient or that are the main
reason for the consultation.
The case discussion method can be one of the best, especially in outpatient clinics.
Teachers should be concerned with discussing and teaching these skills, particularly
those teachers with experience and who recognize that these are the most difficult
and also most needed for the good practice of neurology.
In addition to case discussions, training in the doctor-patient relationship is fundamental.
The neurologist will not have had time to acquire all the life experiences necessary
for the proper understanding of the concerns of his patients. But he may have learned
a lot from observation, reading good books (novels), watching movies or plays, and
discussing cases with his peers and teachers. With this training, the neurologist
will probably be prepared for comprehensive care: to be the primary physician to diagnose,
treat and follow up the patient with neurological disorders. And the neurologist will
be irreplaceable.
