Sheldon Benjamin, MD

Download the recommended core curriculum applicable to both neuropsychiatry and behavioral neurology fellowships table as a PDF.

Articles

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 

 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.

 (ANPA), 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.

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.

Combined neuropsychiatry residencies include the ACGME-specified training in general psychiatry and general neurology. Programs differ as to the amount of integrated neuropsychiatric training, though many include dedicated neuropsychiatry clinics and conferences. Fellowship curricula vary according to the patient population or research focus.

The ANPA Education Committee and the BNS have developed a recommended core curriculum applicable to both neuropsychiatry and behavioral neurology fellowships (available online at http://imaging.cmpmedica.com/CME/pt/content/neurocurr.pdf).

The ANPA Education Committee also maintains an online annotated bibliography of core references in neuropsychiatry under the editorship of Deborah Black, MD, of the University of Toronto.

Given the high-profile advances in neuroscience research of the past few decades and the rapid evolution of available treatments, it might seem surprising at first glance that there are relatively few trainees in combined residencies or fellowship programs in this area. In part, the limited number of trainees is related to the limited number of practicing neuropsychiatrists in the country, resulting in little medical student contact. However, the realities of graduate medical education funding are another important factor. Medicare Part A, which pays for inpatient care for Medicare subscribers, funds hospitals to pay for the salaries and indirect educational expenses for residents in the majority of residency training programs in the United States. Part A funds can only be used for ACGME-accredited residency training and only provide the resident's salary until the time of initial board eligibility. Hospitals are reimbursed only 50% of their direct resident expenses after the fourth year of training, causing hospitals or departments to have to pay the balance of the fifth- and sixth-year salaries themselves. Because they are not eligible for Medicare funding, neuropsychiatry and behavioral neurology fellowship programs tend to rely on research dollars, clinical contracts and departmental funds for support of fellowship expenses, and discontinuities in the funding stream from year to year are not uncommon.

Since 1987, the ACGME and the ABPN have required a minimum of two months of neurology training as part of psychiatry residency training. As of July, they also require one month of psychiatry training as part of neurology residency training. The neurology rotation for psychiatry trainees is supposed to provide sufficient didactic and clinical experience for residents to develop expertise in the diagnosis of neurological problems that might occur in psychiatric practice and require differential diagnosis from primary psychiatric conditions. The ANPA Education Committee has developed a set of more specific neuropsychiatry training objectives for psychiatry residents, the outline of which is listed in Table 4. A referenced version of these objectives with enabling objectives for each topic has been published elsewhere (Benjamin and Mah, 2002). Not all general psychiatry or neurology programs have access to neuropsychiatric faculty, so there is wide variability in resident exposure to neuropsychiatric thinking. Although there are now close to 100 textbooks and 25 journals in neuropsychiatry and related areas, there is still a need for curriculum materials designed to make the neuropsychiatric paradigm accessible to general psychiatry and neurology programs without neuropsychiatric faculty.

Rapid advances in the neuropsychiatric sciences make this an exciting time to practice neuropsychiatry. A wealth of textbooks and journals have emerged in the past 20 years, along with a professional organization providing research forums, continuing education, training resources and opportunities for clinicians and researchers to interact with colleagues from related disciplines. The fields of neuropsychiatry and behavioral neurology are on a path toward eventual accreditation of training programs and certification of practitioners. The timing is excellent for a renaissance of neuropsychiatry training, despite the fact that funding issues, availability of faculty and absence of a formal board-certification process have restrained growth in neuropsychiatric training for the time being.

 Benjamin S, Cummings JL, Duffy JD et al. (1995), Pathways to neuropsychiatry. J Neuropsychiatry Clin Neurosci 7(1):96-101.


 Benjamin S, Mah L (2002), Educational and certification issues in neuropsychiatry. In: The American Psychiatric Publishing Textbook of Neuropsychiatry and Clinical Neurosciences, Yudofsky SC, Hales RE, eds. Washington, D.C.: American Psychiatric Publishing, Inc.


 Coffey CE (1999), The American Neuropsychiatric Association: ten years of progress and a future of great promise. J Neuropsychiatry Clin Neurosci 11(1):8-18.


 Green RC, Benjamin S, Cummings JL (1995), Fellowship programs in behavioral neurology. Neurology 45(3 pt 1):412-415.

The field of neuropsychiatry has undergone tremendous growth over the past few decades. 