Educational Issues in Neuropsychiatry
Educational Issues in Neuropsychiatry
The re-emergence of neuropsychiatry in the 1980s occurred at the beginning of a period of tremendous growth in the neurosciences. With structural neuroimaging (computerized tomography [CT] and magnetic resonance imaging) well established, the promise of functional neuroimaging being realized, and an explosion of advances in neurogenetics and psychopharmacology, investigational tools to allow the study of brain and behavior were becoming available. Forty years earlier, the term neuropsychiatry had been applied to the practice of non-psychoanalytic medical psychiatry. Neuropsychiatrists now define themselves by the diseases they treat (diseases and disorders at the brain-behavior interface), the approach they take to evaluation and treatment, or their area of research interest.
The American Neuropsychiatric Association (ANPA; <www.anpaonline.org>), founded in 1988, is the primary medical organization with which neuropsychiatrists affiliate themselves. The ANPA sponsors annual meetings that focus in depth on neuropsychiatric topics and has the Journal of Neuropsychiatry and Clinical Neuroscience. The ANPA has grown to just under 700 members, including neuropsychiatrists, behavioral neurologists and neuropsychologists. A 1992 survey revealed that 40% of ANPA's members defined their primary practice as psychiatry, 17% as neurology, 15% as both psychiatry and neurology, and 6% as psychology/neuropsychology. The remainder either described their practices as "other" or did not respond (Coffey, 1999).
There is currently no board-certification process for neuropsychiatry. However, a program of voluntary participation in a certification examination and voluntary accreditation of neuropsychiatry fellowship programs is being offered by the ANPA Education Committee. The ANPA, together with the Behavioral Neurology Society (BNS), has just been granted membership in the new Unified Council of Neurological Subspecialties (UCNS) as a first step toward pursuing a formal accreditation and certification process for neuropsychiatrists and behavioral neurologists.
Pathways to Neuropsychiatry
Several training pathways can serve as the foundation for a career in neuropsychiatry (Table 1) (Benjamin et al., 1995). Some neuropsychiatrists train as general psychiatrists or neurologists and enter neuropsychiatry via a practice or research pathway. Combined training in neurology and psychiatry leading to fulfillment of the Accreditation Council for Graduate Medical Education (ACGME) requirements in both fields may be undertaken, enabling the trainee to become eligible for both the neurology and psychiatry board-certification examinations. Combined training requires a minimum of six years, including an internship containing at least eight months of medicine experience and two and one half years spent in each field. If one is planning to practice both psychiatry and neurology, dual board certification is important for inclusion on managed-care panels and may be a prerequisite for dual hospital privileges.
Alternatively, trainees may undergo fellowship training in neuropsychiatry or behavioral neurology (Green et al., 1995) following residency in either psychiatry or neurology. Generally, clinical fellowships are one year in length and research fellowships require two to three years. This pathway will not lead to board eligibility in the complementary field, but it will give the trainee the necessary expertise to practice or conduct research in neuropsychiatry.
There are currently nine ABPN-approved combined neurology/psychiatry residency programs (Table 2), and other programs may be willing to create informal combined neurology/psychiatry training programs on an ad hoc basis. Combined neuropsychiatry programs are approved by the American Board of Psychiatry and Neurology (ABPN), based on each of the host programs being accredited by the ACGME and upon successful review of the proposed curriculum. The total number of combined neuropsychiatry residency programs has not changed significantly in the past five years. Most combined programs participate in the San Francisco Matching Program used by general neurology programs, rather than in the National Residency Matching Program used by medicine and psychiatry programs. As of 2004, an estimated 22 residents were in combined neuropsychiatry training at the nine accredited programs.
Clinical fellowship programs in either behavioral neurology or neuropsychiatry tend to be one year long, and research programs tend to be two to three years in length. Because neuropsychiatry and behavioral neurology are not ACGME-accredited subspecialties, funding and fellowship content vary widely among the approximately 25 fellowship programs.
Fellowship programs known to the ANPA Education Committee are listed in Table 3. Some are primarily geriatric- or dementia-training programs but use a neuropsychiatric or behavioral-neurology paradigm. Many fellowships will accept either psychiatry or neurology graduates.
Fellowship programs listed under both behavioral neurology and neuropsychiatry have separate training directors. Those listed in the table as "BN or NP" will tailor the program toward behavioral neurology or neuropsychiatry.