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Appendix C: Joint Committee on Higher Medical Training Curriculum for Higher Specialist Training in Neurology October 1996
  1. Joint Committee on Higher Medical Training, Royal College of Physicians, 11 St Andrew’s Place, Regent’s park, London NW1 4LE

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    NEUROLOGY

    Entry requirements

    Applicants for Higher Medical Training (HMT) should have completed a minimum of two years General Professional Training (GPT) in approved posts and obtained the MRCP (UK) or (I). A period of experience in neurology at SHO grade is considered desirable before entry to HMT although not essential. Other valuable experience at SHO grade would be in psychiatry, neurosurgery or ophthalmology. GPT should provide a minimum of 24 months involved with direct patient care, at least 12 months of which should be concerned with acute unselected medical intake. Not more than six months of the obligatory two year period may be spent in the neurosciences. Experience in the neurosciences will not be a prerequisite for the successful completion of General Professional Training. Non British graduates without the MRCP who compete for HMT posts must provide evidence of appropriate knowledge, training and experience, particularly in the care of acute medical conditions.

    Duration and organisation of training

    The duration of HMT in neurology is five years. The programme to which the trainee is appointed will have named consultant trainers (Educational Supervisors) for each part of the programme. In addition, one consultant, usually within the same region, but not necessarily involved in the particular training scheme, will act as Programme Director. Upon enrolment with the JCHMT, the trainee will receive a copy of the handbook, the curriculum for Higher Medical Training in Neurology and the training record. A written record of training will be maintained by the trainee, to be counter-signed by the relevant trainer annually; it will remain the property of the trainee but must be produced at the annual assessment. The Programme Director’s responsibility is to ensure that the JCHMT requirements are met, and at each annual meeting suggest any future modifications in training or experience that may be necessary.

    Research

    A period of supervised research of high quality is considered a desirable part of HMT in neurology. A relevant research period may contribute up to twelve months towards the total duration of HMT, the balance to be comprised of clinical training. Trainees may wish to spend two or more years in research, either before starting an HMT programme or by stepping aside from clinical training for a year or more while in post. This is perfectly acceptable but no more than twelve months educational credit will accrue. It will remain essential to acquire the full balance of clinical training. All trainees will be encouraged to undertake research and develop an understanding of research methodology during their period of specialist clinical training. At least l day per week should be made available for study and research throughout the training period.

    Assessment

    Assessment of trainees will be based upon the standard format of annual review the full details of which may be found on page 6 of the Introduction to the JCHMT handbook. The award of the CCST will be based on satisfactory completion of the entire series of annual assessments.

    General description of higher specialist training

    Training in two or more different centres is strongly encouraged. Training in a single centre is undesirable unless that centre is large enough to give a very wide range of experience.

     In the last two years of the training period the trainee must take increasing responsibility, see new patients, undertake ward consultations and operate at a level of responsibility which will prepare him/her for practice as an autonomous Consultant Neurologist. Unless seconded to one of the subspecialties the trainee should undertake three outpatient clinics weekly throughout the training period. This may be reduced to two but never routinely increased to four. The nature of the clinics, and the ratio of new to follow up patients, will depend on the experience of the trainee. New patients should be seen throughout the training period under suitable supervision. This supervision must be close during the first one or two years. Experience in DGH outpatient clinics is encouraged, and at least six months such experience is essential.

     The trainee must be involved in the day to day care of neurological inpatients, supervise their clerking and investigation, and be responsible for the organisation and dictation of discharge summaries. He/she must have experience of organising an inpatient waiting list, counselling patients and their relatives and communicating with general practitioners by post, telephone and at postgraduate meetings.

    Summary of curriculum

    By the end of the five year period the trainee must have obtained experience in clinical neurophysiology, rehabilitation medicine, neurosurgery, intensive care, neuroradiology, head injury and clinical audit. In addition, the trainee is encouraged to obtain experience in neuro-ophthalmology, neuro-otology, neuro-paediatrics, pain management, spinal injury, neuropathology, neurogenetics, neuropsychiatry, uro-neurology and research. More details of topics are given in the full curriculum.

     Subspecialties may be studied on a sessional basis or during a continuous period of release from other duties. Special attention must be paid to clinical neurophysiology, neuroradiology and neurosurgery. The trainee will be required to record the number of EMG clinics and EEG reporting sessions attended, neuroradiology and neuropathology reporting sessions attended and neurosurgical operations witnessed. In the final two years of the training period the trainee may be encouraged to develop a special interest in one of the subspecialties if he/she wishes.

    Clinical audit

    The trainee must participate in monthly clinical audit meetings for at least two years and be responsible for preparing the agenda, attendance and Minutes for at least one year.

    On-call commitment

    For at least three of the five years the trainee must fulfil an on-call commitment no more arduous than 1:4 and no less arduous than 1:8.

    Management

    The trainee must attend at least one approved management course.

    Teaching

    The trainee must have experience of teaching undergraduates, post-graduates, nursing staff and ancillary medical staff.

    Academic posts

    Academic posts, eg. lecturer, are acceptable for Higher Medical Training provided prospective approval has been obtained from the SAC. In some circumstances, the SAC may decide that only part of the time so spent is acceptable.

    Retrospective recognition

    A trainee who has completed his/her General Professional Training and gone directly into a clinical neurology research post may seek retrospective recognition of this post. Approval will not be withheld unreasonably but neurology trainees are strongly advised to seek the advice of the SAC before committing themselves to a particular research post.

    Training abroad

    A period of training overseas will be permitted for one year and is encouraged after formal recruitment to HMT, provided the training programme receives prospective approval.

    Prospective approval

    It cannot be emphasised too strongly to both trainees and supervising consultants that any training programme should be carefully thought out. If either party has any doubts about the matter, prospective advice should be sought from the SAC to avoid disappointment if retrospective recognition is not granted or is limited. This applies particularly to academic and research posts.

    Training record

    The training record will include a register of specialised procedures (eg lumbar puncture, muscle biopsy), supervision of ventilated patients, outpatient clinics, subspecialty attendance, clinical audit meetings, grand rounds, conferences, postgraduate and management courses and on-call commitments. During any research year the training record will include an account of research and clinical work undertaken. The trainee will meet his/her programme director at the end of each year and submit the account for approval. The programme director will certify the training undertaken and, if necessary, advise the trainee and his/her trainer about any shortcomings of the trainee or the training posts, with suggestions how to remedy these in the coming year.

    Dual certification

    It may well be that trainees will seek dual certification in Neurology and Clinical Neurophysiology, or Neurology and Rehabilitation Medicine. Precise arrangements for such joint training programmes will be for negotiation between the relevant SACs and will usually involve some lengthening of the overall training period.

    Flexible training

    Details of arrangements for flexible training will be found in the NHSE Guide to Specialist Registrar Training (March 1996).

    CURRICULUM

    A sound knowledge of neuroanatomy and neurophysiology; and ability to take a neurological history and carry out a detailed neurological examination are essential. By the end of the five year period the trainee must have obtained experience in clinical neurophysiology, rehabilitation medicine, neurosurgery, intensive care, neuroradiology, head injury, clinical audit and research. In addition, the trainee is encouraged to obtain experience in neuro-ophthalmology, neuro-otology, neuro-paediatrics, pain management, spinal injury, neuropathology, neurogenetics, neuropsychiatry, uro-neurology.

     Subspecialties may be studied on a sessional basis or during a continuous period of release from other duties. Special attention must be paid to neurophysiology, neuroradiology and neurosurgery. The trainee will be required to record the number of EMG clinics and EEG reporting sessions attended, neuroradiology and neuropathology reporting sessions attended and neurosurgical operations witnessed.

     In the final two years of the training period the trainee may be encouraged to develop a special interest in one of the subspecialties if he/she wishes. Specialist registrars in neurology should ensure that they attend teaching sessions and/or read widely on the topics listed below. No one textbook of neurology is particularly recommended but trainees are expected to purchase and be familiar with at least one major neurology textbook, and to have regularly consulted key references and the latest issues of the major neurological journals.

    The major areas to be covered in the course of Neurology HMT are listed below, with the principal topics to be addressed within each area:-

    1 Neuro-ophthalmology

    • Examination of the visual system

    • Visual pathways and assessment of visual fields

    • Practical demonstration of various perimeters

    • Visual failure and cortical disturbances of vision

    • Eye movement disorders

    2 Neuro-otology

    • Mechanisms of hearing and balance

    • Neuro-otological tests with practical demonstrations and their interpretation

    • Assessment of the dizzy patient and treatment

    3 Disorders of the cranial nerves/Isolated cranial nerve palsies

    • Optic neuropathy

    • Trigeminal and glossopharyngeal neuralgia

    • Multiple cranial nerve palsies

    4 Neuropsychiatry

    • Psychological features of cerebral disorders

    • Neurology of neurosis, anxiety and depression

    • Psychotic illness

    • Somatisation disorders, including hysteria

    5 Clinical neuropsychology

    • Assessment of cognitive functions at the bedside

    • Detailed psychometric testing

    • Intelligence

    • Memory

    • Language and its disorders

    • Other cortical functions

    • Counselling skills

    6 Neuroradiology

    • Radiological and vascular anatomy

    • Imaging the brain: CT, MRI, SPECT, PET

    • Imaging the cerebral circulation

    • Carotid ultrasound

    • Imaging the spinal cord

    • Interventional neuroradiology and the new techniques

    • Risks of radiological techniques and costs

    7 Clinical neurophysiology

    • Electroencephalography

    • Video-EEG telemetry

    • Nerve conduction studies and electromyography

    • Evoked responses and intra-operative monitoring

    • Magnetic stimulation

    • Magnetoencephalography

    8 Cerebrospinal fluid

    • Lumbar puncture

    • Physiology and constituents of CSF

    • Disorders of intracranial pressure

    9 Dementia

    • Investigation of the demented patient

    • Differential diagnosis and management of dementia

    • The neuropathology of the dementias

    10 Cerebrovascular disease

    • Acute treatment of stroke

    • Carotid surgery and angioplasty

    • Investigation strategies, risks and costs

    • Prevention strategies

    • Management of stroke, Stroke Units

    • Cerebral infarction

    • Cerebral haemorrhage

    • Subarachnoid haemorrhage

    • Arteriovenous malformations

    • Intracranial venous thrombosis

    • Arteritis and vasculitis

    11 Epilepsy

    • Differential diagnosis

    • Blackouts and funny turns including non-epileptic attacks

    • Investigation strategy

    • Treatment strategies

    • Social and psychological factors

    • The management of refractory seizures

    • Status epilepticus

    • Surgery for epilepsy and other treatments eg vagal stimulation

    12 Sleep disorders

    • Normal sleep, EEG of sleep, uses of sleep laboratory

    • Sleep apnoea

    • The parasomnias: narcolepsy, cataplexy, night terrors, sleep walking etc

    13 Disorders of consciousness

    • Acute confusional states

    • Assessment of the comatose patient

    • Persistent vegetative state

    • Brain death

    14 Demyelinating diseases

    • Pathogenesis of MS

    • Diagnostic criteria: when and how to tell the patient

    • Symptomatic management

    • Treatment strategies: review of recent trials

    • Management of the patient with chronic MS

    • Other demyelinating diseases

    • Repair and regeneration in the central nervous system

    15 Neuroimmunology

    • Basic immunology

    • Autoimmune disease at the neuromuscular junction

    • Neurology of the connective tissue disorders

    • Anti-phospholipid syndromes

    • Sarcoid

    • Immunosuppressive treatment

    • Immunoglobulin therapy

    16 Headache

    • Evaluation and classification of headache

    • Management of migraine and other headaches including temporal arteritis

    • Chronic daily headache

    17 Movement disorders

    • Parkinson’s disease, pathogenesis

    • Treatment strategies including management of dyskinesias and the on/off patient

    • Surgery and transplantation

    • Multisystem atrophy

    • Involuntary movements

    • Dystonic syndromes

    • The use of botulinum toxin

    18 Neurogenetics

    • Basic terminology eg exon, codon, crosshybridization

    • Mitochondrial inheritance, mitochondrial disorders

    • Gene therapy

    • Genetic counselling

    • Huntington’s disease

    • Hereditary ataxias and neuropathies

    • Neurofibromatosis and other neurocutaneous syndromes

    • Other inherited metabolic and degenerative disorders

    19 Head injury

    • Acute assessment and treatment of head injury

    • Extra aural and sub-dural haematomas

    • Post-traumatic syndromes

    • Medico-legal considerations

    20 Infections

    • Acute and chronic meningitis, cerebral abscess and sub-dural empyema

    • Encephalitis

    • HIV

    • Syphilis

    • Lyme disease

    • Poliomyelitis

    • Tropical infections

    21 Disorders of the spine and spinal cord

    • Spinal cord compression

    • Cervical radiculopathy, spondylosis and myelopathy

    • Cauda equine syndromes

    • Management and sequelae of spinal injuries

    • Spinal cord ischaemia and haemorrhage

    • Subacute combined degeneration

    22 Uro-neurology

    • Assessment of disorders of micturition and sexual function

    • Management of disorders of micturition

    • Management of disorders of sexual function

    23 Neuromuscular disorders

    • Investigation of peripheral neuropathy

    • Acute and chronic inflammatory neuropathies,

    • The plexopathies and entrapment syndromes

    • The dystrophies and myopathies

    • Motor neurone disease

    • Polymyositis and dermatomyositis

    24 Autonomic nervous system

    • Autonomic failure: diagnosis and treatment

    • Disorders of swallowing and respiration

    25 Pain

    • Mechanisms and patho-physiology of pain

    • Management of chronic pain eg trigeminal neuralgia and facial pain

    • Reflex sympathetic dystrophy

    • The role and scope of pain clinics

    26 Neuro-oncology

    • The neuropathology of brain tumours

    • Surgery, radiotherapy and chemotherapy

    • Treatment of malignant brain tumours

    • Spinal tumours

    • Treatment of low grade gliomas

    • The paraneoplastic syndromes

    • Malignant meningitis

    27 Neurological intensive care

    • Management of airway and respiration

    • Swallowing difficulties

    • Cardiovascular support

    • Nutrition

    • Psychological consequences

    • Brain stem death criteria and organ donation in practice

    28 Neurological rehabilitation

    • Assessment of impairment, disability and handicap

    • Rehabilitation of patients with stroke, head and spinal injury

    • Psychosocial aspects of rehabilitation, disability and handicap

    • Organizational and management aspects of rehabilitation

    • Social work legislation and care in the community

    29 Neuro-paediatrics

    • Assessment of delayed development

    • Degenerative disorders

    • Epilepsy

    • Funny turns

    • The clumsy child

    • The floppy child

    30 Neurosurgery

    Surgical management of:

     Head and spinal injuries

     Subdural and other intracranial haematomas

     Intracranial tumour

     Intracranial aneurysm

     Posterior fossa lesion

     Cervical spine/cord disease

     Lumbar spine disease

     Muscle and nerve biopsies

    31 Neuropathology

    • Staining methods and techniques

    • Major pathological abnormalities affecting central nervous system, peripheral

    nerve and muscle:

    Congenital

    Inflammatory

    Infective

    Neoplastic

    Vascular

    Degenerative

    • Forensic neuropathology

    32 Neuropharmacology

    • Principles of clinical neuropharmacology

    • Neurotransmitters

    • Drug interactions

    33 Neuroendocrinology

    • Pituitary tumours

    • Diabetes and the nervous system

    • Hypothyroidism

    34 Neurotoxicology

    • Neurotoxins

    • Heavy metal poisoning

    • Alcohol

    35 Neurology of particular patient groups

    • Reproductive females and pregnancy

    • The elderly

    • Developing countries

    36 Research and audit methodology

    • How to do research

    • How to involve patients and control subjects in research projects

    • How to get a grant

    • How to apply to an ethics committee

    • Clinical trials: what to do and not to do

    • Statistics - to include the meta-analyses

    • Cochrane collaboration

    • How to read a scientific paper

    • Audit

    37 General skills

    • Presentation and communication skills

    • Information technology and its application

    • Knowledge of the neurological charities

    • Breaking bad news

    • Dealing with the difficult patient

    • Palliative care

    • Dealing with uncertainty

    • Writing a medico-legal report

    • Developing a business plan

    • Chairing a committee

    • Dealing with complaints

    38 Management

    • Structure and management of the NHS

    • Running a clinical service

    • Achieving service developments

    View Abstract

    Footnotes

    • * Patient consulting rates are rates of patients who consulted their general practitioner for the cited diagnosis at least once in the study year.

    • The figures in the fourth Survey in 1991 reflect face to face contacts in 60 general practices, excluding temporary residents. The study sample of 468 042 person-years at risk was representative of the 1991 census population in terms of age, sex, marital status, housing tenure, economic position, occupation, urban/rural distribution, and smoking history.

    • This paper was first published in J Neurol Neurosurg Psychiatry 1996;61:242–9.

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