On a bit of a whim today, I decided to go back to the blog that I kept before I started this one, and wound up importing and then reading through almost all of my old entries (fifty of them! a bigger task than I bargained for).  I have kept their original posting dates; anything from 2006 or 2007 is from the old blog.

I started that blog when I began medical school, and although it was the right decision for a number of reasons (logistical and otherwise) for me to switch to this blog, going back and incorporating most of those entries today was very powerful.  I feel I am reclaiming my experiences across the gulf that separates me from the first two years of medical school, which were much more didactic and abstract, but also times of great idealism and excitement about my profession.  Rereading them, I don’t feel that I have lost too much of that idealism or enthusiasm now that I have more clinical experience, despite the inevitable bumps and bruises of third year.   And that was part of the whole point of blogging during medical school in the first place.

Reposting those entries also encourages me to acknowledge the role that spirituality and spiritual exploration played for me earlier in medical school.  Although I no longer identify with any particular religion or participate in any formal spiritual practice, I think the lessons I learned from attending a Unitarian Universalist congregation and learning about Buddhist meditation have not been forgotten, just sublimated into the underlying whole of who I am, how I live my life, and how I will practice medicine.  The previous blog was explicitly about both spirituality and medicine.  In this one, I didn’t set out to discuss anything other than medicine, but especially for a pattern-finder like me, medicine has come to relate to every other aspect of my life and so this blog has wound up being no less inclusive.

Finally, about the patients.  I started this new blog in part because I wanted to stop blogging anonymously, feeling that it does a disservice to myself, my colleagues, and especially to my patients and their stories if I write under the false comfort of anonymity.  As they say, there is no anonymity on the internet.  But more importantly, I never want to use this blog or anything else I write as an outlet to say things I would not say otherwise, publicly.  This is my voice, speaking about my experiences, and for that voice to be genuine I feel I have to claim it with my name.  That also means I fully embrace the responsibility of telling patients’ stories in ways that contribute to a larger understanding of health and medicine, without revealing their identities and without exploiting their shortcomings.  I have struggled a lot this year about how best to approach this last point, recognizing that humans are imperfect and that their (our) imperfections often are what contribute to poor health, bad outcomes, negative relationships, or unsuccessful interactions and interventions.  I think these stories can be retold and learned from in a professional manner, without any judgment or criticism of specific patients or medical providers, and looking back I see that the stories I have told since the beginning of medical school have in fact been overwhelmingly positive.  Rereading individual stories also made me realize how vivid these people and interactions still are for me as much as three years later.  I reflected on this in a writing exercise a while back in which I wrote again about Ms. A., and realized that though writing about her had preserved many of the details of the experience for me, there were other details I remembered that I had not blogged about at the time.  The whole experience was more vivid because I had written it down, not as a rote recording of facts for the future, but as a way to relive it and to universalize its messages so that they can be applied to future patient interactions. These people I have met during my medical education are the soul of this blog, and, of course, the soul of this profession. I think they would have stayed with me regardless of whether I wrote about them or not, but I firmly believe that reflective writing has revealed the messages of each experience to me in a deeply meaningful and important way. Through writing, I have seen past the surface of these interactions, opened up avenues of patterns and connections between larger themes, and become more fully present to my own experiences: emotions, reactions, missteps, and the fire that keeps burning, keeps me going, as I start to approach the end of this phase of my medical education.

Here’s a nice brief piece from the New York Times on the cognitive abilities of babies and young children. A number of the research studies and findings mentioned are classics of child psychology, and I don’t know that saying that “in some ways, [children] are smarter than adults” really means much. But I like the direction Gopnik takes it next:

Sadly, some parents are likely to take the wrong lessons from these experiments and conclude that they need programs and products that will make their babies even smarter. Many think that babies, like adults, should learn in a focused, planned way. So parents put their young children in academic-enrichment classes or use flashcards to get them to recognize the alphabet. Government programs like No Child Left Behind urge preschools to be more like schools, with instruction in specific skills.

That's a lot of brain for a little baby.

One of the basic experimental paradigms in research with young children as subjects relies upon their innate tendency to look, and look longer, at whatever is new or unexpected for them.  This is the ultimate in self-directed learning, in which babies design their own curriculum by devoting more attention to the stimuli that will teach them the most.  What I take away from this article is an affirmation that young children are pre-programmed to learn, and that with appropriately supportive environments–most of all, the attention of loving caregivers–learning is what they will do.

To quote the great neuroscientist Louis Armstrong,

I hear babies cry
I watch them grow
they’ll learn much more
than I’ll ever know
and I think to myself
what a wonderful world

On a related note, I would encourage anyone interested in education to head over to the website for the master’s thesis project of my fourth grade teacher, Kent Daniels. His unusual classroom was filled with computers, couches, camaraderie, and the most self-directed learning I did until probably college. He treated us nine-year-olds like adults, but he also clearly kept alive many of the same innate drives to learn that we had had since early childhood. Scroll down through this page, or use the search bar throughout the website, for some discussion of our student-created “learning contracts” and the experiential basis for our education that year. Again, this formative experience for me and for decades of Kent’s students is a far cry from the educational approaches and priorities of No Child Left Behind and other regimented instruction. It takes incredibly dedicated and creative teachers like Kent to make classrooms challenging and enriching for all students, but I do hope that continued inquiry into child brain development and educational psychology will inform future educational policy and maybe swing the pendulum back towards something that retains that joyful hunger for learning that children have in their earliest years.

The short answer is… my future career!

I know I have mentioned in my time capsule posts that Child Neurology has been my intended specialty for a while, but as of this week it is official, because I just submitted my application and distribution list to the San Francisco Match.  I will definitely spend more time later talking about why Child Neurology, but I wanted to put together an introduction to what Child Neurology is.  It’s a field that not a lot of medical students are aware of, and I get lots of questions about it whenever I tell someone that it is my future specialty, so hopefully people happening across this post will find it helpful.

What is a Child Neurologist?

Child Neurology – also known as Pediatric Neurology – is a subspecialty combining pediatrics and neurology (see below for training).  It has been board-certified since 1969.  A Child Neurologist diagnoses and treats the disorders of the brain and the rest of the nervous system in children and adolescents.  The common, “bread and butter” conditions of Child Neurology include epilepsy (seizure disorder),  headache, and behavioral and developmental disorders like autism and ADHD.  The scope of a Child Neurology practice ranges from these to more rare genetic, neuromuscular, metabolic, and degenerative diseases affecting the nervous system.  Here is a helpful information sheet from the American Academy of Pediatrics, geared towards parents.  Like most specialties, the scope of ways to practice Child Neurology is broad, and can include private or academic practice, inpatient or outpatient.  The age range seen by Child Neurologists includes young adulthood all the way down to the immediate newborn period.

According to the American Medical Association’s Physician Professional Data, there were 1,352 Child Neurologists in the US in 2008.  This is 0.44 per 100,000 people.  (By comparison, there were 59,441 pediatricians which is 19.3 per 100,000, although I am not sure if that is just general pediatricians or includes subspecialists.)  This included 805 mainly office-based Child Neurologists, 229 hospital-based residents, and 176 hospital-based staff physicians.  According to the Association of American Medical Colleges, the median income for a Child Neurologist in academic practice in 2008 was $146,000 for “early career” (assistant professors) and $191,000 for “mid to late career” (associate and full professors).  By comparison, the figures for a pediatrician in academic practice were $136,000/$167,000, and for an adult neurologist in academic practice $139,000/$191,000.  (All of this information is from the AAMC Careers in Medicine subspecialty pages, which is a great resource for medical students that requires a password from your office of student affairs.)

A Child Neurology Society workforce study in 2003 estimated 817 full-time equivalent Child Neurologists, which is 1.14 per 100,000 children in the US.  They reported an average income of $149,787, with academic faculty earning less than their colleagues in other practice settings.  Child Neurologists earned about $18,000 less than other pediatric subspecialists, and about $22,000 less than adult neurologists.  Although Child Neurology is not a heavily procedure-oriented subspecialty, 70% of survery respondents reported performing or interpreting electroencephalograms for reimbursement, 16% perform electromyelograms and nerve conduction studies, and 60% perform lumbar punctures.

Several sources report that Child Neurologists have the highest levels of career satisfaction of all subspecialists.

What is Child Neurology training like?

The standard training for a Child Neurologist is:

• four years of medical school (the M.D.)
• two years of a Pediatrics residency (they are usually three years long, though some people “fast-track” into other pediatric subspecialties and do only two)
• three years of a Child Neurology “advanced residency”, one year of which is adult neurology

After the five years of residency, a Child Neurologist is eligible to become “double-boarded”, with board certification in both Pediatrics and Neurology with a Special Qualification in Child Neurology.  Some people go on to do additional fellowship training in epileptology, neuromuscular, stroke, and so on.  Also, there are some variations from the training path I outlined above, including doing more than two years of pediatrics residency, doing one year of neuroscience research and one year of pediatrics, or doing one year of internal medicine and one year of pediatrics before entering the Child Neurology residency.  Finally, a few programs have combined five-year residencies that include both the pediatrics and the child neurology components.

There is also a separate residency program in Neurodevelopmental Disabilities (NDD), a newer subspecialty you can read about here.  This requires two years of pediatrics residency followed by four years of NDD residency.  Many training programs offer both Child Neurology and NDD positions.

How do you apply to become a Child Neurologist?

An important thing for medical students to be aware of is that you can apply to Child Neurology residency directly from medical school, unlike most other pediatric subspecialties where you apply after the start of your pediatrics residency.  Here’s how it works:

1. Through the San Francisco Match or “Early Match”, you apply for the Child Neurology residency position that you will start in your third year after you graduate medical school (post-graduate year three, or “PGY-3″).  I graduate in 2010, so I will start my Child Neurology residency in the summer of 2012.  The application deadline and other dates for this match process are earlier than the regular match; it varies from program to program, but the target date given by the SFMatch is August 26 for this year.  The online application opens in June.  You interview in September through December (mostly October and November, I have heard) and then you submit your rank list and find out where you matched in January.
2. You apply to the Pediatrics residency position the same way you normally would, through ERAS (the regular match).

“Word on the street” has it that this may all change in coming years and that everything will be through ERAS, so this information may not be accurate in the future, but to the best of my knowledge it is now.

***Addendum: If you are California-bound, UCSF now has a requirement that Step 2 CK and Step 2 CS be completed and that a passing score be reported before they will rank you for their residency programs, including Child Neurology. This means you will need to make sure to take these exams early, possibly before your school’s required deadline. I don’t want to be the last word on this, so please check with them even if you are applying this cycle and think you won’t be able to take the exams in time.***

There are currently about 76 programs offering Child Neurology training, and about 9 offering NDD training.  There are Child Neurology programs in all areas of the country, both in and outside of major urban centers.  Most programs have one or two positions per year; the largest have four and five.

Do we need more Child Neurologists?

Yes.  A 1998 AAN taskforce estimated that there was approximately a 20% staffing shortage relative to the demand for Child Neurology services.  A follow-up study in 2003 confirmed that waiting times to obtain an appointment with a Child Neurologist were on average 49 days, which most respondents considered excessive.  They also found that referrals to Child Neurologists were increasing, and that in most cases this demand could not adequately be met by general pediatricians or adult neurologists.  Not all slots in Child Neurology training programs are being filled, so the shortage of Child Neurologists is expected to continue at least until 2020.  This brings me back to the beginning of my post: I hope to help spread the word to medical students about the field of Child Neurology, so that more people will consider this satisfying and in-demand subspecialty.

Useful links:

Child Neurology Society (CNS) – A professional society for child neurologists with a great acronym. Check out their free education membership with access to their child neurology case studies.
Child Neurology Foundation – The outreach and philanthropic arm of the CNS. They offered summer research scholarships to medical students interested in child neurology until the recent economic downturn, and hopefully they will resume this program in the future.
American Academy of Neurology (AAN)
American Academy of Pediatrics (AAP)
San Francisco Match: Child Neurology – Includes everything you need to know about the application process for Child Neurology and NDD residencies. The program directory is only available to current applicants.
AAMC Careers in Medicine – Password-protected site with information about specialty and subspecialty training, practice characteristics, compensation, demographics, and even personality types.

Have questions?

I am no expert on this, but I am very happy to talk to other students who are considering Child Neurology or others with questions about the field.  You can contact me by leaving a comment on this post or by clicking the Contact link in the upper right hand corner of the page.  Thanks for reading.