Neurology residency programs in U.S.A.

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The United States (U.S.) has one of the most well-organized nationwide systems for postgraduate neurology training. In most U.S. programs, in addition to the day-to-day experiences, a defined curriculum covers all required learning subjects. The Accreditation Council for Graduate Medical Education (ACGME) ascertains that each residency program meets its requirements. The requirements consist of (1) personnel including the director, teaching staff, residents and other program personnel, (2) clinical and educational facilities and resources including an intensive care unit, inpatient and outpatient facilities with examining areas and conference rooms, offices, clinical laboratory services and a library, (3) educational program including a curriculum, seminars and conferences, teaching rounds and clinical and basic science teaching with adequate resident/patient ratio and faculty/resident ratio. The program must provide training diagnostic skills, experiences in both inpatient and outpatient services, elective and subspecialty experiences, resident participation in research and teaching, and evaluation of the program by the residents. ACGME also looks at the program performance in the board examination and inservice examination. Responsibility, leave policy and benefits are defined in a written contract. Because of these accreditation requirements and the structured teaching program, the quality of U.S. residency programs is relatively uniform around the intended standard. Compared with the U.S. programs, the quality of the program appears to rely on the quality of mentors and institutions in Japan, and many facilities may not satisfy the requirements equivalent to that defined by the ACGME. Today, U.S. neurology residency programs face a number of challenges. The health care reform shifted the weight of medical services towards the primary and ambulatory care. This has resulted in a dramatic decrease in the number of applications from U.S. medical school graduates. As a result, the number of neurology residency positions must be decreased and unfilled positions must be filled by international medical school graduates. The quality of international medial school graduates varies significantly. The recently proposed simple quota for international medical graduates per institution may eliminate opportunities to recruit excellent international medical graduates and may prevent selections of residents purely based on their merit. Emphasis of the training must shift towards outpatient care. Medicare views medical care provided by residents insufficient for billing by the attending physicians in academic institutions, making residents a financially ineffective work force. The training program may become a labor- intense and expensive burden for many neurology departments. Because teaching hospital accept many tertiary referral patients who require complex and expensive diagnostic tests and treatments, the average cost of care per patient appears higher than that in average private neurology practice. In spite of the training cost and estimated higher patient care cost, the third payers do not sufficiently take these factors into considerations in the reimbursement. Thus, cost containment is a major concern at teaching institutions. Since containment of medical cost is a major issue and health care reform is ongoing in Japan, Japanese training programs may face similar problems. While we may take advantage of adopting some of the ACGME guidelines for establishment of highly standardized residency programs in Japan, the society's need for neurologists, impacts of health care reform and costs of resident training should be carefully considered in the process.

Original languageEnglish (US)
Number of pages1
JournalClinical Neurology
Issue number12
StatePublished - Jan 1 1997

ASJC Scopus subject areas

  • Clinical Neurology


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