Neurology

What got you interested in Neurology as a Specialist Interest?

From medical school until the final months of core training, I wanted to be a neurologist.  I found the inner workings of the nervous system, and how it is affected by disease, fascinating.  I enjoyed the ‘puzzle’ that neurological problems can pose, as well as the satisfaction that diagnosing and treating the problem brings. 

ACCS Acute Medicine exposed me to elements of medicine that I found just as exciting as diagnostics.  Treating the critically unwell patient, mastering practical skills, and managing the ebb and flow of the Acute Medical Unit steered me into the life of an acute physician (that, and some amazing acute physicians that most SAM members will know all too well!). When it came to deciding a specialist skill it really was a “no brainer” – marrying all that I loved about medicine in one neat package!

In my opinion, Neurology as a special skill perfectly complements the role of an acute physician.  At ‘the front door’, there is a relative paucity of neurology skills and experience disproportionate to the sheer number of acute neurological presentations that we as receiving doctors care for.  I have found ‘practical neurology’ in the acute medical unit adds tremendous value to patients, and colleagues through sharing my experience.

How did you train in Neurology and what other avenues are available?

Developing my special interest in neurology was initially somewhat daunting.  There wasn’t a well trodden path as there is with many other available specialist skills.  I spoke to senior colleagues and expressed my desire to undertake a six-month dedicated neurology block well in advance.  My TPD put me in touch with his neurology counter-part, who was extremely welcoming and enthusiastic.  We met and exchanged in emails over several months to determine what the block would actually look like.  During this process, I was put in contact with many other neurology consultants and SpRs all too willing to guide and mentor me too – I quickly became a novelty!   

We agreed what would be practical for an acute physician to learn – the hyper-specialist genetic neuromuscular junction clinic probably wasn’t going to be the place for me for 6 months!  Headache, epilepsy and seizures, functional neurology, and other common acute presentations like confusional states, weakness and sensory change formed the main foci of my attachment.

Being less than full time, I spent two days a week in a mid-size district general hospital, doing general neurology clinics and assisting consultants with inpatient referrals and liaison.  This happened to give me a lot of one-on-one time with neurologists subspecialising in headache and epilepsy, which was fantastic! I spent the other two days of my normal working week within the tertiary centre, attending useful specialist clinics, working alongside Neurology SpRs in the rapid access neurology clinic and attending as much teaching as I could! Taking this all together, I felt this was pretty realistic exposure to bread-and-butter neurology that one might encounter as an acute physician.

An alternative route would be to undertake a post-graduate diploma or certificate in Neurology. I applied to such a qualification, but given the huge amount of resource this would have demanded in time, effort, and money, in addition to working and having a young family, I opted for the more practical ‘on-the job’ option.  Whilst I’m not sure there’s a perfect substitute for hands-on experience, I would consider doing this in future to expand my knowledge further!

What challenges did you face?

The enthusiasm I was met with, from colleagues within both Acute Medicine and Neurology camps quickly offset the lack of a clear path I mentioned above! Don’t let being in the minority put you off, whatever your specialist interest!

There is a steep learning curve. I encountered conditions I’d never heard of most weeks, if not days.  How to make and manage these diagnoses was harder still.  Fortunately, patient mentors understanding my background, and the sheer abundance of learning opportunities in a tertiary centre made keeping up with the learning curve a little easier.  Where it didn’t,  I found keeping a note book of helpful pointers and areas for further reading was essential.      

The way of working is different too.  As acute physicians, we’re used to managing a broad-range of conditions in a time sensitive manner, often in a busy environment where the focus of our attention shifts frequently, and often suddenly as the situation demands!  It takes time to shift your mindset to the intensive, incredibly detailed approach required to conduct a neurological history and examination.  Furthermore the long-term logistics of chronic neurological illness such as disability, prognosis and heritability, things that aren’t always the priority in AMU, are just as important as the immediate diagnosis and management in the neurology clinic.

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How do you see this being part of your consultant job?

As a senior trainee, and hopefully soon a consultant, I hope the experience and skills gained during my neurology training will form an integral part of my day-to-day acute medicine practice. As I mentioned neurological presentations to the acute medical unit are common —headache, seizures, acute confusional states and “tingly bits” just to name a few.  Being able to confidently manage many of these cases will not only improve the initial patient experience at the front door, but also reduce unnecessary investigations and referrals to tertiary services.  On the same note, I foresee using these skills to provide a strong alternative to hospital admission for patients with neurological presentations – whether in the form of ambulatory pathways, virtual wards or “rapid-review” of patients in admission environments.

It goes without saying, none of the above would be possible without maintaining strong relationships with neurologists. I hope to act as a bridge between acute medicine and neurology wherever I work, not only to ensure patients presenting with neurological disease  get to the right clinician at the right time, but foster collaboration when it comes to education and developing pathways for common conditions and presentations.

I also envision sharing my skills and experience with colleagues, junior and contemporaries alike, and hope that I can help to demystify what many still see as a difficult and complicated field of medicine.

Do you have any tips for trainees who may be interested in Neurology as a special interest?

1. Be proactive! Talk to your training programme director early, and make connections with a neurologist keen to champion your cause – it might take some time to build a neurology placement that works for you! Seek out opportunities to gain exposure to neurology during training, whether through formal rotations, joining the neurology team review when you refer a patient, or arranging supervised clinics if you aren’t yet at the stage of your special skill!

2. Focus on what’s relevant: Neurology is a huge field, and as such it can be intimidating and hard to know where to start.  Decide on a small handful of things you either enjoy, find interesting, or that stump you in your day to day practice, and focus on those things during your time in neurology.  You’ll accidentally learn loads of other things whilst you’re there!

3. Make use of resources: Take advantage of online courses, podcasts, and webinars to supplement your learning. I attend national neurology training days to stay up to date and further my education, and I couldn’t recommend them more once you’ve done your block!

4. Stay curious: You’ll definitely come across things during your neurology time you never knew you’d be interested in – embrace it! I never thought I’d be so interested in headache and facial pain!

Neurology as a specialist interest offers a unique opportunity to develop skills that are directly applicable to acute medicine, whilst offering great opportunities to broaden your skillset. If you love a diagnostic challenge and enjoy a multidisciplinary approach to patient care, it is an immensely rewarding specialist skill!

Feel free to email me with any questions you have, or are interested in making neurology your own specialist skill in acute medicine! Chris.speakman@nhs.scot