Results from a 2017 survey shared at the 2018 annual meeting of the American Association of Neuromuscular & Electrodiagnostic Medicine (AANEM) illustrate significant disparities in the amount of training that neurology and physical medicine and rehabilitation (PMR) residents receive in electrodiagnostic (EDX) medicine.
“Our data showed a great difference in how programs teach EDX medicine, including nerve conduction studies (NCSs) and particularly electromyography (EMG). The differences included duration of training in weeks, supervision, independence in performing NCSs and EMG, continuous or fragmented training, the training years of residency, the number of attending physicians teaching the residents, organized conferences, the number of NCSs and needle EMGs performed, and exposure to pathology material,” stated AANEM member Peter D. Donofrio, MD.
Dr. Donofrio and Raghav Govindarajan, MD, distributed approximately 400 surveys to neurology and PMR residency programs on 24 topics related to the training of residents in the technique and performance of peripheral EDX medicine. Of the programs that responded, 65% were neurology, 35% were PMR.
The survey results were as follows:
- Average Training Time for EDX:
- Neurology Residency Programs: 8.4 weeks (Range 0-52 weeks).
- PMR Residency Programs: 21.3 weeks (Range 8-48 weeks).
- The sequence of training was continuous in 50% of programs and fragmented in 50%.
- EDX training primarily occurred in second and third years of residency.
- Training in needle EMG was required in 94% of programs.
- Performance of the needle examination was observational only in 8% of programs and in 61% of programs, the trainee was supervised continuously by faculty.
- More than 80% of programs conducted organized needle EMG and neuromuscular teaching conferences as part of the rotation.
- The majority of programs had 3 or more attending physicians teaching EDX.
- The number of NCSs performed independently varied greatly among the programs.
The findings clearly indicate disparity in the amount of EDX training across residency programs and that PMR residents receive substantially more EDX training. Dr. Donofrio said he was not surprised by the results.
“The findings were in keeping with my expectations as I anticipated the range of the data would be broad, particularly for neurology training programs. This is actually one of the reasons I pursued this study,” Dr. Donofrio explained. “The disparities have many explanations. Some are historical, as EMGs are not emphasized in some training programs. Additionally, residents are heavily involved in inpatient and outpatient medicine and the time to teach EMG is lessened by other neurology and PMR forces such as inpatient wards, inpatient consults, emergency room responsibilities, sicker patients, residents’ desire to have more electives, 80 hour work weeks, and the list goes on.”
The training disparities can have a significant impact on patient care.
“Probably the biggest impact is in the area of private practice where there are many neurologists out in the community doing EMG with limited training. This does not happen in PMR where all residents are required to be fully trained within their residency – PMR requires 6 months of EMG, neurology requires zero. As a result, neurologists who are interested in neurophysiology and neuromuscular medicine end up receiving their EDX training during their fellowships,” explained Eric J. Sorenson, MD, and Past President of the AANEM.
“On one hand, it is very reassuring that PMR residencies continue to focus on providing an excellent training experience in EDX, but on the other hand, neurology residencies have a very wide variability in training. The field of neurology has become highly subspecialized – 15 different kinds of fellowships and counting – but a basic understanding of peripheral nerve/muscle disease and the role of EDX in their diagnosis and management is still an essential part of a neurologist’s arsenal and is needed irrespective of how subspecialized we become,” noted Dr. Govindarajan.
Anthony E. Chiodo, MD, MBA, and current AANEM President, says that while training programs may differ in the amount of time dedicated to EDX medicine, neurology and PMR physicians can demonstrate their knowledge in EDX by becoming certified by the American Board of Electrodiagnostic Medicine (ABEM) and receiving EDX Laboratory Accreditation through the AANEM.
“Receiving ABEM board certification and ensuring your EDX laboratory is accredited demonstrates an important bar of achievement and robust EDX standards, so patient care is assured,” said Dr. Chiodo.
Now that the survey results have been tallied and distributed, Dr. Govindarajan says the next step will be to create a white paper that can be shared with the Accreditation Council for Graduate Medical Education (ACGME) and other accreditation bodies on the recommended minimum requirements of EDX training for neurology residents.
“This will hopefully streamline and create uniform training standards across residencies in the country,” noted Dr. Govindarajan.