Primary care perceptions of neurology and neurology services

Degenerative Cervical Myelopathy Awareness in Primary Care: UK National Cross-Sectional Survey of General Practitioners

BACKGROUND

Degenerative cervical myelopathy (DCM) is a progressive neurological condition, characterized by spinal cord injury secondary to degenerative changes in the spine. Misdiagnosis in primary care forms part of a complex picture leading to an average diagnostic delay of 2 years. This leads to potentially preventable and permanent disability. A lack of awareness secondary to deficits in postgraduate education may contribute to these delays.

OBJECTIVE

This study aims to assess the awareness of DCM in the setting of general practice.

METHODS

General practitioners completed a quantitative web-based cross-sectional questionnaire. The 17-item questionnaire captured data regarding demographics, subjective awareness, and objective knowledge. The questionnaire was disseminated via professional networks, including via practice managers and senior practice partners. Incentivization was provided via a bespoke DCM fact sheet for those that completed the survey.

RESULTS

A total of 54 general practitioners representing all 4 UK nations responded to the survey. General practitioners most commonly self-assessed that they had "limited awareness" of DCM (n=24, 51%). General practitioners felt most commonly "moderately able" to recognize a case of DCM (n=21, 46%). In total, 13% (n=6) of respondents reported that they would not be at all able to recognize a patient with DCM. Respondents most commonly reported that they were "moderately confident" in their ability to triage a patient with DCM (n=19, 41%). A quarter of respondents reported no prior introduction to DCM throughout their medical training (n=13, 25%). The mean score for knowledge-based questions was 42.6% (SD 3.96%) with the lowest performance observed in patient demographic and clinical recognition items.

CONCLUSIONS

General practitioners lack confidence in the recognition and management of DCM. These findings are consistent with the diagnostic delays previously described in the literature at the primary care level. Further work to develop and implement educational interventions to general practitioner practices is a crucial step to improving patient outcomes in DCM.

Investigation of Neurophobia amongst North American Veterinary Students and Development of a Veterinary Neurophobia Scoring Tool (VetNeuroQ)

"Neurophobia" is a phenomenon in human medical education where students develop negative attitudes towards neurology, impeding student learning and future clinical practice. While suspected to exist in veterinary medical education, it remains unstudied. The main objectives of this study were to examine North American veterinary student attitudes towards neurology and neurology education and explore elements that might contribute to neurophobia. Additional objectives were to evaluate veterinary educators' perceptions of student neurophobia and to develop and validate a scoring tool (VetNeuroQ) to quantify veterinary neurophobia. Veterinary students and faculty at North American veterinary schools were surveyed. A scoring tool was developed from a subset of questions and validated using confirmatory factor analysis. Six hundred six anonymous responses were collected from students at all stages of veterinary education. Neurology training was reported as insufficient by 35.9% and most respondents perceived neurology to not be easy to learn. Neuroanatomy/physiology and neurolocalization were considered difficult concepts. Students rated low confidence in neurology (vs. other topics), and low interest in the Neurology/Neurosurgery specialty. 61.7% of educators reported neurophobia amongst their students. The proposed VetNeuroQ scale showed high reliability (Cronbach's alpha >0.7) and validity (p < .05; CFI >0.9, RMSEA <0.08). VetNeuroQ scores were low but improved over the course of veterinary education. These findings demonstrate low self-efficacy, interest, and confidence, along with perceptions of difficulty, amongst veterinary students, consistent with neurophobia. Contributing elements are discussed. The VetNeuroQ scale allows quantification of veterinary student neurophobia and may be useful for screening students and assessing the impact of educational interventions.

The Role of the Neurological Examination in Primary Care Referrals to Neurology

Low confidence with the neurological examination may contribute to primary care physicians' discomfort with neurology and a low threshold to refer patients. We surveyed primary care physicians in Quebec about their last three referrals to neurology to evaluate what role the neurological examination played in their decision. Twenty-six physicians answered concerning 73 patient referrals. We found that primary care physicians use the neurological examination to reinforce their decision but rarely depend on the findings. Our results suggest that improving history-taking rather than examination skills may have more impact on neurology referrals, influencing quality of referral information above quantity of referrals.

Understanding the ongoing learning needs of Australian metropolitan, rural and remote paediatricians: Evaluation of a neurology outreach programme

AIM

The purpose of this study was to evaluate whether a neurology outreach teaching programme delivered via video-teleconferencing (6 × 60 min live sessions every 6-8 weeks) is acceptable, contributes to understanding and meets the neurology learning needs of Australian paediatricians from metropolitan, rural and remote areas.

METHODS

A sample of six NSW sites that joined the neurology outreach programme between 2017 and 2019 (Arm 1) and six interstate sites from QLD, WA and TAS who commenced the programme in 2020 (Arm 2) participated. A mixed-methods survey explored participants' learning needs and value of the programme.

RESULTS

Forty-six participants submitted programme evaluation surveys (26 arm 1, 20 arm 2); 9 were removed due to insufficient data (n = 37). Quantitative and qualitative data showed the programme was acceptable in format, relevant to practice, appropriate for clinician learning needs, and engaging. Clinicians reported improvement in understanding and confidence. Participants felt more connected/less isolated and up-to-date. Participants reported a positive impact from the programme on approach to neurological problems and ensuing consults, and more differentiated and appropriate paediatric neurology referrals.

CONCLUSION

This study validates the live video-teleconference outreach model as an acceptable, effective and important means of providing continuing neurology education for Australian paediatricians.

Improving Awareness Could Transform Outcomes in Degenerative Cervical Myelopathy [AO Spine RECODE-DCM Research Priority Number 1]

STUDY DESIGN

Literature Review (Narrative).

OBJECTIVE

To introduce the number one research priority for Degenerative Cervical Myelopathy (DCM): Raising Awareness.

METHODS

Raising awareness has been recognized by AO Spine RECODE-DCM as the number one research priority. This article reviews the evidence that awareness is low, the potential drivers, and why this must be addressed. Case studies of success from other diseases are also reviewed, drawing potential parallels and opportunities for DCM.

RESULTS

DCM may affect as many as 1 in 50 adults, yet few will receive a diagnosis and those that do will wait many years for it. This leads to poorer outcomes from surgery and greater disability. DCM is rarely featured in healthcare professional training programs and has received relatively little research funding (<2% of Amyotrophic Lateral Sclerosis or Multiple Sclerosis over the last 25 years). The transformation of stroke and acute coronary syndrome services, from a position of best supportive care with occasional surgery over 50 years ago, to avoidable disability today, represents transferable examples of success and potential opportunities for DCM. Central to this is raising awareness.

CONCLUSION

Despite the devastating burden on the patient, recognition across research, clinical practice, and healthcare policy are limited. DCM represents a significant unmet need that must become an international public health priority.

Key concepts and opportunities

Neuropalliative care is an emerging field dedicated to applying palliative care approaches to meet the needs of persons living with neurologic illness and their families. The development of this field acknowledges the unique needs of this population, including in terms of neuropsychiatric symptoms, the impact of neurologic illness on personhood, and the logistics of managing neurologic disability. In defining the goals of this field, it is important to distinguish between neuropalliative care as an approach to care, as a skillset, as a medical subspecialty, and as a public health goal as each of these constructs offers their own contributions and opportunities. As a newly emerging field, there are nearly unlimited opportunities to improve care through research, clinical care, education, and advocacy.

NeuroQ: A neurophobia screening tool assesses how roleplay challenges neurophobia

BACKGROUND

Neurophobia is a chronic disease of medical students and junior doctors. Early detection is needed to facilitate prevention and management as this fear can negatively impact patient care.

METHODS

We conducted a two-part mono-centric study at the faculty of Medicine, Sorbonne University, in Paris. Part one: a cross-sectional study to validate a newly constructed neurophobia scale, NeuroQ. Part two: a prospective longitudinal study to assess the impact of The Move on student neurophobia using NeuroQ. A population-based sample of second-year medical students of the 2019 and 2020 class of the Faculty of Medicine of Sorbonne University were invited to participate.

RESULTS

NeuroQ incorporates the main themes of the neurophobia definition and demonstrates uni-dimensionality. Three hundred and ninety-five medical students participated in the study (mean age was 20.0 years, SD: 2.1 years) assessing the effect of The Move teaching on neurophobia. Two hundred and eighty-eight (72.9%) students were female. After the Move teaching the mean NeuroQ score was significantly lower compared to the baseline NeuroQ score (mean [SD] variation, -1.1 [2.6], p < 0.001). There was a 22.3% relative reduction in the number of neurophobic students after The Move teaching.

CONCLUSION

Our results highlight the utility of NeuroQ in assessing (i) baseline neurophobia and (ii) the impact of pre-clinical educational interventions on neurophobia. Furthermore, we have shown the importance of pre-clinical educational interventions, such as The Move, in tackling neurophobia.

An evaluation of optimal tutorial methodologies for neurology teaching at undergraduate level : Optimal tutorial methods for neurology

AIM

We aim to determine the efficacy of an intensive week of large group tutorials in the teaching of neurology to medical students. We also look to compare teaching methods within our centre.

METHODS

Students were asked to complete a questionnaire before and after large group tutorials ranking their confidence in neurology. Students from two consecutive years were studied, each using a different tutorial method. An 'intensive week' approach was then compared to a 'once a week' approach.

RESULTS

Responses from pre and post the tutorial week were compared. Students reported an improvement in all domains following either method of delivering tutorials. There was no statistically significant difference between the two approaches.

CONCLUSION

Large group tutorials are an effective way of delivering neurology teaching to undergraduate medical students.

Quantitative analysis of medical students' and physicians' knowledge of degenerative cervical myelopathy

OBJECTIVES

We have previously identified a delay in general practitioner (GP) referrals for patients with degenerative cervical myelopathy (DCM). The aim of this study was to evaluate whether an education gap existed for DCM along the GP training pathway by quantitatively assessing training in, and knowledge of, this condition.

DESIGN

Gap analysis: comparison of DCM to other conditions. Comparators selected on the basis of similar presentation/epidemiology (multiple sclerosis), an important spinal emergency (cauda equina syndrome) and a common disease (diabetes mellitus).

SUBJECTS

Medical students, foundation doctors and GP trainees. PRIMARY AND SECONDARY OUTCOME MEASURES: (1) Assessment of training: quantitative comparison of references to DCM in curricula (undergraduate/postgraduate) and commonly used textbooks (Oxford Handbook Series), to other conditions using modal ranks. (2) Assessment of knowledge: using standardised questions placed in an online question-bank (Passmedicine). Results were presented relative to the question-bank mean (+/-).

RESULTS

DCM had the lowest modal rank of references to the condition in curricula analysis and second lowest modal rank in textbook analysis. In knowledge analysis questions were attempted 127 457 times. Performance for DCM questions in themes of presentation (+6.1%), workup (+0.1%) and management (+1.8%) were all greater than the question-bank mean and within one SD. For students and junior trainees, there was a serial decrease in performance from presentation and workup (-0.7% to +10.4% relative to question-bank mean) and management (-0.6% to -3.9% relative to question-bank mean).

CONCLUSIONS

Although infrequently cited in curricula and learning resources, knowledge relating to DCM was above average. However, knowledge relating to its management was relatively poor.

Team conflict and the neurologist

Collaboration within a complicated organization is inherently challenging and can be fraught with discord. Recent emphasis on interdisciplinary and collaborative teamwork in neurology has brought this issue to the forefront of daily practice. The health care system can be complex and opaque, and the stakes-human life-are high. Medical team conflict has been associated with decreased subjective effectiveness, less job satisfaction, and increase in errors. As specialists, neurologists are necessarily embedded within a network of providers and must be adept in the understanding and management of conflictual situations. For the practicing neurologist, it is important to understand team conflict dynamics. Here, management strategies are provided that illustrate how individual neurologists can serve as effective leaders who mitigate harmful effects and capitalize on benefits of team conflict on performance.

Neurologic and neuroscience education

Neurologic disorders are among the most frequent causes of morbidity and mortality in the United States. Moreover, the current shortfall of neurologists is expected to worsen over the coming decade. As a consequence, many patients with neurologic disorders will be treated by physicians and primary care providers without formal neurologic training. Furthermore, a pervasive and well-described fear of neurology, termed neurophobia, has been identified in medical student cohorts, residents, and among general practitioners. In this article, members of the American Academy of Neurology A.B. Baker Section on Neurological Education review current guidelines regarding neurologic and neuroscience education, contextualize the genesis and the negative consequences of neurophobia, and provide strategies to mitigate it for purposes of mentoring future generations of health care providers.

The reliable measurement of temporal trends in mortality attributed to epilepsy and status epilepticus in Northern Ireland between 2001-2015

PURPOSE

Epilepsy mortality is of considerable public health concern, as a leading cause of premature neurological death. Recent English and Welsh mortality data suggests a falling mortality rate where epilepsy was the underlying cause of death, predominantly due to a reduction in status epilepticus (SE) mortality. We sought to validate this finding in Northern Ireland.

METHODS

Officially recorded death certificate data related to epilepsy and SE were obtained from the Northern Ireland statistics and research agency. Data were analysed from 2001 to 2015. The outcomes were the age-adjusted mortality rate for epilepsy and SE. External validation of SE deaths was carried out using data from an intensive care national audit and research centre database.

RESULTS

From 2001 until end of 2015, epilepsy was recorded at death certification in 1484 cases. 458 deaths were considered due to epilepsy. Among 75 in whom SE was recorded, SE was the cause of death in 46 patients. External validation found 103 total deaths related to SE in ICU departments in Northern Ireland, suggesting an overall under-ascertainment of officially recorded statistics. With respect to the 2013 European Standard Population, the mean age-adjusted mortality rate for epilepsy was 1.9 (95% C.I. 1.73-2.07) per 100,000 person years. For SE the mean age-adjusted mortality rate was 2.1 (95% C.I. 0.15-0.27) per 100,000 person years.

CONCLUSIONS

Death certification in SE is likely to be an underestimate of the reality. Further efforts are urgently needed to determine the extent of SE-related deaths and all deaths in patients with epilepsy.

Referral management: Which patients are deemed not appropriate for neurologic consultation, and what happens to them?

OBJECTIVE

In many if not most institutions in the US, demand for neurology services exceeds the supply, resulting in poor access. This study examines whether the use of a limited resource - time for outpatient neurology consultation - can be optimized by screening referrals for appropriateness and whether it is safe to do so.

PATIENTS AND METHODS

An established triage activity at an academic outpatient clinic - experienced nurses flagging possibly inappropriate outpatient referrals and a group of neurologists triaging them - was examined by obtaining referral characteristics and detailed one year follow up for patients that were referred but not scheduled, over a period of 6 months. A narrative of issues related to this activity is provided as well.

RESULTS

180 "Declined" referrals were identified. Most frequent reason for declined referral were pain, headache and dizziness. The most frequently recommended disposition was follow up with the referring primary care physician (32%), pain or spine clinic (11%) or reevaluation by a previously involved outside neurologist (12%). Review of follow up care - as far as available - indicated that in the majority of cases (52%), no further neurologic evaluation was pursued. Triage was considered reasonably safe (i.e. very little if any pathology was missed or work up delayed). In 15%, referring providers tried to circumvent the triage system by various means; we also felt that the option to reach the triaging neurologist was rather underused and that at least a fraction of referring physicians disapproved of triage efforts.

CONCLUSIONS

Triaging referrals by chart review appears to be safe, but its effectiveness is limited by the time investment, limited acceptance by some referring providers and other factors.

Patient reported experiences of using community rehabilitation and/or support services whilst living with a long-term neurological condition: a qualitative systematic review and meta-aggregation

Objectives: The objective of this study is to identify patient reported experiences of using community rehabilitation and/or support services whilst living with a long-term neurological condition, and perceptions of their impact on quality of life.Methods: Nine electronic databases were searched for peer-reviewed qualitative studies from 2005 to 2016, which met the inclusion criteria. Critical appraisal, data extraction, and quality assessment of 37 included papers were performed by three reviewers. One hundred and one findings were extracted. Meta-aggregation was used to synthesize findings.Findings: Seven 'synthesized findings' [SF] were produced: Interactions with some professionals provide active participation, choice, confidence and autonomy [SF1]; Interactions with some professionals are disempowering and depersonalized [SF2]; Effective communication, specialist knowledge and an individualized approach to information provision is needed [SF3]; Indicators of success vary and may not be clear [SF4]; Informal support from family/friends is valued [SF5]; Opportunities for peer support/social interaction is valued [SF6]; Coordination required to ensure continuity during transition to community [SF7].Conclusion: Patient reported experiences identified common factors associated with process quality (respect, choice, autonomy, information provision, communication) and activities of patient centered care (personalized care, shared decision-making, self-management support) despite heterogeneity of neurological conditions, service configurations, and geographical location. These factors impact quality of life.Implications for RehabilitationPatient reported experiences provide useful information about courtesy, respect, choice, autonomy, information provision, and communication.Outcomes of self-efficacy and self-management are important for people with stable and progressive long-term neurological conditions.Interactions with individual professionals influence engagement, self-efficacy, and self-management for people with long-term neurological conditions.Training for health and social care professionals should develop the advanced communication skills and behavior required to facilitate self-efficacy and self-management.

Neuroanatomy education: The impact on perceptions, attitudes, and knowledge of an intensive course on general practice residents

General practitioners are responsible for the management of an increasing number of patients with neurological illness, and thus a solid education in neurosciences is a necessary component of their training. This study examines the effects of an intensive clinical neuroanatomy course on twenty general practice residents' perceptions, attitudes, and knowledge. A knowledge test was completed by the participants and by a control group at four different time points. The participants were asked to answer a questionnaire about their reasons for signing up for the course and their attitudes and perceptions toward the course experience. Experimental and control groups demonstrated identical mean baseline test scores. The experimental group significantly increased its test scores (plus 49.0% correct answers, a mean improvement of 120%) relative to controls after the educational intervention. There were no differences among scores from the evaluated time points after the educational intervention in the experimental group. In the control group, there were likewise no significant differences between the four evaluated time points. Most participants indicated that they signed up for the course to update/acquire knowledge and skills in the field of neurosciences, and also because they had difficulty in diagnosing and managing patients with neurological diseases. Participants' attitudes and perceptions toward the course experience were very positive. Most of the participants (n = 17; 85%) rated the course as "extremely useful," and 3 (15%) rated it as "very useful." This study provides evidence demonstrating the potential positive effect of neurosciences education to general practice residents. Anat Sci Educ 10: 465-474. © 2017 American Association of Anatomists.

What Do Medical Students Know about Deep Brain Stimulation?

BACKGROUND

Deep brain stimulation (DBS) is an established therapy for movement disorders. It is currently under investigation in neuropsychiatric disorders. Neurophobia is a common phenomenon that might have a negative impact in medical education. Little is known about medical students' knowledge about DBS when they enter university and what they learn about it during their medical formation.

METHODS

A 10-item questionnaire was designed. Questions addressed indications for DBS, costs of DBS, complications, the percentage of Parkinson disease (PD) patients who might profit from DBS, etc. Students at Hannover Medical School were asked to complete the questionnaire in the preclinical study period and in the last year of the study.

RESULTS

Comparing the "early group" (204 students) and the "advanced group" (162 students), there was a significant gain of knowledge. More common disorders such as PD and tremor were known to be indications for DBS. Knowledge about the impact of DBS on specific symptoms in PD and about DBS targets was limited in both groups.

CONCLUSIONS

DBS is partly known among medical students in the preclinical phase with a gain of knowledge during further study. Future studies on this topic addressing general practitioners as neurologists are needed to better understand why knowledge on DBS is still limited.