By Meah Mingyang Gao, MD; Russell Rasquinha, MD, MASc; Manav V. Vyas, MBBS, MSc; Mary Jane Lim Fat, MD; Yuri Kiryanov, MD; Clecio Godeiro, MD, PhD; Fernando Morgadinho Coelho, MD, PhD; Dalia Rotstein, MD, MPH, FRCPC; Tim Patterson; and Morris Freedman, MD, FRCP

A screenshot of NIRVE rounds in September 2015 — First round for the new cycle (2015-16) where all sites introduce themselves. Top left: Slides being presented at the NIRVE rounds from Toronto. Top right: Trainees and staff at Ufa, Russia; and below, trainees and staff at St Petersburg, Russia. Bottom left: Natal, Brazil, and Sà£o Paulo, Brazil.

The 2013 WFN neurology training survey highlighted great variability in neurology training programs across the world.¹ Neurology trainees are interested in international clinical experiences, but are often constrained by limited flexible time as well as financial, educational or logistical support.² With the advent of modern technology, 95 percent of current international neurology trainees have reliable Internet access.¹ Video-conferenced medical rounds are a new and proven way to supplement medical education across distances and may represent a sustainable solution to global peer learning.^3,4

The Neurology International Residents Videoconference and Exchange (NIRVE) is a resident initiative sponsored by the Peter A. Silverman Global e-Health Program, the Canada International Scientific Exchange Program (CISEPO) and the Baycrest Center for Geriatric Care in Toronto. In 2009, Dr. Dalia Rotstein, a former neurology resident and now faculty member at the University of Toronto, established NIRVE with the vision to connect neurology residents across various geographical sites. NIRVE was modeled on the International Behavioral Neurology Videoconference Rounds.⁵

Figure 1. 61 distinct round topics (main case and image challenge) at 45 NIRVE rounds

NIRVE was designed to develop leadership skills and create opportunities for residents at all levels to participate in medical education and peer learning, raise awareness of global health concepts in neurology, increase resident advocacy of global health issues, enhance international and national collaboration among neurology residents and act as a gateway for organizing on-site exchanges.

The participating international sites on a rotating basis host the rounds every first Thursday morning of the month. Residents from the host site present a neurology case through videoconferencing technologies, and neurology resident moderators encourage the audience to actively engage in discussions and exchange opinions in real time.

Since its inception, NIRVE has continued to grow and expand. Neurology residents, fellows and faculty from Toronto with international contacts or affiliations initially recruited partner sites. For example, Olga Finlayson, a former University of Toronto neurology resident, helped establish a lasting collaboration and later clinical exchange with the First State Pavlov University in St. Petersburg, Russia. Our current partner sites include Natal, Brazil; Sà£o Paulo, Brazil; Grenoble, France; Jos, Nigeria; and Ufa, Russia. Participation is free and any site in the world with videoconference technology is welcome to join NIRVE as an equal partner.

Methods

Table 1. Results for educational value of NIRVE rounds in 2015 (N = 25)

The rounds start at 8 a.m. Eastern time, with a 30-minute case presentation and a 15-minute “image challenge” focused on a radiological or pathological diagnosis, with accompanying neuro-images. The rounds include sufficient time to engage residents in discussions involving diagnostic steps and therapeutic management across the different international sites. The current video-conferencing equipment (H.323/SIP connection protocol) is free within Ontario. International sites connect through a video conference MCU or bridge (Resolve Collaboration) at an hourly rate of slightly more than $35 per site (sponsored by the Peter A. Silverman Global e-Health Program, CISEPO and Baycrest Center for Geriatric Care).⁵ As of 2015, webcasting with password protection has been implemented using the Ontario Telemedicine Network, allowing any resident with Internet to connect to our rounds.⁶

As a resident-led initiative, NIRVE values all input from its participants and actively seeks feedback to further improve the program and curriculum to cater to participant needs. In 2015, a formal survey was distributed to all NIRVE participants and site directors from 2014-2015. The questionnaire consisted of four parts: demographic information, questions on the main case presentation, questions on the image challenge and exchange participation. The survey assessed both qualitative and quantitative responses from the participants and was administered using Survey Monkey^®.

Results

More than 100 trainees from 10 different sites have attended NIRVE rounds since its inception. Figure 1 shows the categories and number of presentations in each category that have been covered at the NIRVE rounds, with neurovascular and neuroinfectious diseases being the two most common.

Twenty-seven, or 60 percent, of the 45 trainees across four different sites participated in the survey. The average age of these trainees between the ages of 24 to 53 was 29.4 years, and 16, or 60 percent of trainees, were females. While most were neurology residents at different levels of training, two  sub-specialty fellows, one postdoctoral fellow and two PhD students also participated in the survey. Slightly more than 66 percent of trainees identified languages other than English as the language of instruction in their medical training. Of the 25 residents surveyed, 91.6 percent thought that the rounds were relevant to their level of training, 95.8 percent identified that the rounds contributed to their existing knowledge and 87.5 percent agreed that the topics align with their academic interests (Table 1). Seventy-two percent of trainees were interested in presenting at the rounds in the future, and 80 percent indicated an interest in participating in a future clinical exchange program. Most trainees identified the case discussions as the most beneficial aspect of the rounds and suggestions were made to increase emphasis on global health topics and comparing and contrasting practices across the world.

Discussion

There are considerable variations in the occurrence and management of neurological conditions across the world. As neurology trainees prepare for their future careers in an increasingly globalized world, providing early exposure to a variety of cases and management strategies can be challenging. NIRVE provides an opportunity to fill this gap while fostering a platform for potential collaborations.

Over the past years, NIRVE has encountered considerable challenges limiting its expansion. The difference in time zones across countries, various costs associated with room rental and equipment purchase for some international sites, and English as the main language for the rounds have limited the number of trainees we have been able to engage. Looking to the future, creating a bigger role for webcasting, and password-protected archived webcasts could be a more cost-effective strategy to expand our reach. However, increased connectivity may come at the price of reduced real-time interaction. Finally, an on-site clinical exchange is planned for May 2016 in Toronto, including participants from Brazil, Canada and Russia.

Conclusion

Despite challenges including technological, logistical and language-related constraints, NIRVE rounds continue to supplement resident learning across different geographical, political and cultural backgrounds. We welcome residents and fellows from other programs to contact us at nirve.utoronto@gmail.com for more information about NIRVE or to participate in NIRVE. We are happy to provide further information on some technical requirements and further details.

References

1. Steck A, Struhal W, Sergay SM, Grisold W and the Education Committee World Federation of Neurology. The global perspective on neurology training: the World Federation of Neurology survey. J Neurol Sci. 2013; 334(1-2):30-47
2. Lyons JL, Coleman ME, Engstrom JW, Mateen FJ. International electives in neurology training: a survey of US and Canadian program directors. Neurology. 2014; 82(2): 119-25
3. Ali J, Sorvari A, Camera S, Kinach M, Mohammed S, Pandya A. Telemedicine as a potential medium for teaching the Advanced Trauma Life Support (ATLS) course. Journal of Surgical Education. 2013; 70(2): 258-264
4. Ricci MA, Caputo MP, Callas PW, and Gagne M. The use of Telemedicine for delivering continuing medical education in rural communities. Telemedicine and e-Health. 2005; 11(2): 124-129
5. Patterson T, Gouider R and Freedman M. Canada, Tunisia Link up for Long Distance Education. World Neurology. 2012; 27(1): 8
6. Brown EM. The Ontario Telemedicine Network: a case report. Telemed J E Health. 2013; 19(5):373-6

By Ricardo Nitrini, MD

Ricardo Nitrini, MD

When I was invited to give the presentation “Successful Training in Neurology in Latin America” at the 2015 World Congress of Neurology in Santiago, Chile, I tried to answer the question, “What is the best way to train a neurologist in Latin America?”

To analyze the current situation, I emailed Latin American leaders in neurology, seeking information on graduate courses of medicine, residency programs and the number of neurologists in their countries. Most of my suggestions are based on more than 40 years of experience in clinical practice as a neurologist and in teaching neurology in a Latin American country. So, they are not scientifically proven assertions and should be regarded as a specialist’s opinion.

First, a well-trained Latin American neurologist should be able to provide the best treatment for patients with neurological diseases, teach all medical doctors to treat and recognize the most common neurological diseases that should be referred to neurologists, and research methods of the prevention, diagnosis and treatment of neurological diseases, mainly those that are more frequent in Latin American countries.

First step: Neurology in the Medical School

Ricardo Nitrini, MD (back row, center), faculty and residents from the University of Sà£o Paulo, Brazil, gather for a photo.

We need to attract the best medical students to be neurologists.¹ To accomplish this, it’s important to fight “neurophobia” during the graduate course. Two main actions are important for this purpose – avoiding teaching excessive techniques of neurological examination in a short period of time and changing the old idea that neurology is great for diagnosis, but not for treatment. Neurologists can do much for their patients and will do much more in the near future.

Most Latin American medical schools do not have neurology departments. The information I received from seven Latin American countries showed that there were only 42 such departments in 307 medical schools, and the teaching of clinical neurology has been delivered by both neurologists and other medical doctors in the large majority of these schools. Thus, it’s important for medical schools to establish neurology departments and deliver instruction through trained neurologists.

The formation of Neurologists in Latin America

Most European countries require a four-year minimum of postgraduate training in neurology.^2,3 This contrasts with postgraduate training in neurology in Latin American countries (minimum two years in Brazil and three years in the majority). In the U.S., residency programs are three years long (preceded by a year of internal medicine training).⁴

To obtain more successful training, we need to have longer residency programs (at least three years dedicated to clinical neurology) to incorporate the expanding field of neurological practice. We may also stimulate residents to undertake short-term elective training in other Latin American centers and abroad.

Research

It is essential to improve research on the prevention, diagnosis and treatment of neurological diseases in Latin America, particularly those more prevalent in Latin American countries. Neurologists should be trained during graduate and residency programs on basic aspects of medical research to be able to interpret results and conclusions of papers, and should learn how to submit and publish manuscripts in indexed journals.

More Well-trained Neurologists

The Neurology Atlas (WHO 2004) showed that the median number of neurologists per 100,000 in population varies widely across regions, from 0.03 in Africa to 4.84 in Europe. In the Americas, this figure was 0.89, but there was no specific data from Latin American countries.⁵ Information I received from 11 Latin American countries showed that this number ranges from 0.3 to 3.7, with a median of 0.9. The appropriate number of neurologists in the population depends upon the structure of a country’s health care system.⁴ In low-income countries, such as Latin American countries, there are large inequities across regions. In Brazil, for instance, the number of neurologists ranges from less than five in five of the 26 states to more than 200 in four states.⁶

We need more neurologists, but, as is frequent in several regions of the world, there are more applicants than positions for residency training in neurology.³

Conclusions

We need to attract the best medical students to become clinical neurologists, to extend the residency program time, to teach basic aspects of research on clinical neurology during residency programs, and to increase the positions for residency programs in neurology in order to increase the number of well-trained neurologists. To reach this objective, we should develop combined actions of local neurological societies and public health authorities, and also to increase cooperation between Latin American countries and with developed countries.

Acknowledgements

I am grateful for information provided by Drs. Daniel Raú
l Zuin, Argentina; Juan Carlos Duran, Bolivia; Renato Verdugo, Chile; German Perez-Romero, Colombia; Guillermo Jiménez, Dominican Republic; Ildefonso Rodriguez Leyva, México; Walter Samuel Diaz, Nicaragua; Fernando Gracia, Panama; Nilton Custodio, Peru; and Santiago Fontiveros, Venezuela. •

References

1. Russell Brain. Neurology: Past, present, and future. Br Med J 1958; 5067:355-360.
2. Bergen DC, Good D. Neurology training program worldwide: a world federation of neurology survey. J Neurol Sci 2006;246:59-64.
3. Steck A, Struhal W, Sergay SM, Grisold W, Education Committee World Federation of Neurology. The global perspective on neurology training: the world federation of neurology survey. J Neurol Sci 2013;334:30-47.
4. http://www2.massgeneral.org/neurologyresidents/program/curriculum.html
5. Atlas. Country Resources for Neurological Disorders 2004. Geneva: World Health Organization and World Federation of Neurology, 2004.
6. Amorim HA, Scorza CA, Cavalheiro EA, Albuquerque M, Scorza FA. Profile of neurologists in Brazil; a glimpse into the future of epilepsy and sudden unexpected death in epilepsy. Clinics 2013;68:896-898.

By Vladislav Voitenkov, MD, PhD

Dr. Voitenkov during EMG symposium

The large scientific meeting, Clinical Neurophysiology and Neurophysiology, was held by the Scientific Research Institute of Children’s Infections in St. Petersburg, Russia, November 26-27, 2015. Held at the Mosckovskye Vorota Congress Center in St. Petersburg, the event attracted 395 participants.

The scientific program was dedicated to general problems of neurophysiology in Russia, Commonwealth of Independent States countries and the European Union, and to certain methods in neurophysiology and neurorehabilitation. The congress hosted plenary lectures and 10 symposiums in all. Plenary lectures included such themes as modern aspects of meningitis and encephalitis treatment and diagnosis in pediatrics, presented by Professor N. Skripchenko of the Scientific Research Institute of Children’s Infections, recent discoveries in the field of transcranial magnetic stimulation (TMS), including TMS-MRI fusion techniques, presented by Dr. B. Neggers, University Medical Center Utrecht Brain Center, the Netherlands, and the role and place of electrophysiology in modern medicine, presented by Professor L. Sumsky, Neurology Center, Moscow.

Dr. Neggers during TMS-MRI fusion workshop

Symposia themes were vast and issues included scientific and clinical aspects of electromyography,  electroencephalography, neurorehabilitation, ultrasonography of the brain, muscles and peripheral nerves, neuro-orthopedics, electrophysiology and audiology, neurorehabilitation and nurses’ education. Special interest was dedicated to the TMS symposium, which gathered more than 100 participants and 12 speakers, including Professor J. Mally of the Institute for Neurorehabilitation in Sopron, Hungary. He presented material on TMS as a diagnostic and therapeutic tool. Professor N. Nazarenko of the Diagnostic Center for Altay Region, Barnaul, Russia presented data on TMS investigation in tick-borne encephalitis and many others.

The previous congress, which took place in 2015 was dedicated to more general topics and had a more classic design. This year’s event was more inclusive of the newest techniques, approaches and more advanced methods.

Professor Skripchenko on TMS findings in encephalitis in children

At the meeting, 126 speakers presented their data on the topics. Symposia included talks from leading Russian and international speakers, as well as presentations from early career researchers whose material has had a significant impact in their fields. Delegates for the congress gathered from Russia, Ukraine, Belorussia, Germany, Austria, the Netherlands and Hungary. Russian delegates came from more than 90 locations, including the Far East and Arctic Northern provinces of the country.

Professor Mally on non-invasive brain stimulation.

The meeting garnered positive and warm feedback from the delegates and speakers. The organizing committee is now deep into the planning of the next event, which will take place in St. Petersburg at the end of November 2016.

Pictured, left to right: Professor Reinhold Schmidt, president of the Austrian Society of Neurology; Dr. Hanna Demissie Belay, assistant professor, department of neurology at Addis Ababa University, Ethiopa; Dr. Kalpesh Jivan (South Africa) and Professor Wolfgang Grisold, WFN secretary general.

First, I have the deepest appreciation and gratitude to the World Federation of Neurology and Austrian Neurological Society for endorsing the African Initiative and introducing and supporting the department visit program. I would like to thank Professor Wolfgang Grisold and Professor Eduard Auff for their kind welcome and for hosting me at the Medical University of Vienna in October 2015. I wish to express my sincere thanks to Professor Fritz Zimprich, who was my mentor and made my stay incredibly productive and interesting. I would also like to thank Tanjia Weinhart for effectively arranging my stay from the very beginning up to the end. I thank profusely all the hospital staff of AKH Wien for their kind help and cooperation throughout my stay.

I started my visit in the department of neurology with an introduction and warm welcome from all the staff and the head of the department. I started my training on the neurology ward, where, initially, I was overwhelmed by the size and complexity of the hospital. The department of neurology, alone, occupied two floors for inpatient services and another floor for outpatient services.

I spent my first week in inpatient services on the neuromuscular ward and later in the neurorehabilation unit. I was able to follow acute management of neuromuscular disorders and rare cases, including anti-NMDA receptor encephalitis, which I saw for the first time. I spent a day with the occupational therapists, speech therapists, physiotherapists and other members of the team. I was impressed to see how intense and well coordinated the rehabilitation process was. It further strengthened my conviction that rehabilitation is of utmost importance in the management of many neurological patients. During this time, I was introduced to techniques that I may also apply at my home department. I have decided to try establishing a neurorehabilitation unit in one of the hospitals affiliated with our university. Since my visit, I joined Addis Ababa University in Ethiopia as a faculty member. If successful, it will be the first of its kind in the country.

Among the highlights of my stay was the third week in which I spent in the epilepsy monitoring unit. I observed invasive electrode implantation, and I was lucky enough to attend awake epilepsy surgery. Witnessing something you have had only the chance to read about before was amazing. During the rest of the time, I attended the epilepsy clinic and followed a number of complex epilepsy cases.

I spent half days of week three on the electrophysiology units (NCS, EMG, EP and ultrasound). I was impressed to see how useful ultrasound examination could be in the evaluation of many neurological diseases. I plan to collaborate with our colleagues in the department of radiology to eventually establish a similar service at my home institution. I spent a few days with the neuro-interventionalist, where I observed certain procedures not practiced within our department.

I spent time at different specialty clinics and learned much from everyone involved. By week four, I attended different specialty clinics, such as the neuromuscular unit, as well as the multiple sclerosis, epilepsy, headache, vertigo and Parkinson’s disease clinics. Each unit was a stimulating experience. At the vertigo clinic, for the first time, I could see electronystagmography being performed on a patient. During a night shift, I learned how to evaluate and confirm brain death.

I was invited to give a talk on the practice of neurology in Ethiopia. I got to talk about my country, the burden of neurological disease in our setting, how neurology is being practiced, which neurological disorders are common and how we manage them. The audience was attentive, and the post-talk discussion was very lively. It allowed me to share my experiences and describe working conditions on “the other side of the world.”

I also had the privilege to visit another hospital, Kaiser Franz Josef Spital and attend a tumor board session, guided by Professor Wolfgang Grisold. I found it to be interesting, and it can easily be adapted to a set up like ours.

My stay in Vienna was not only formally educational, but it also gave me the opportunity to meet neurologists from Austria and share experiences.

My weekends were always full, and Vienna fascinated me with its timeless beauty, culture and artistic attractions. It felt like heaven to walk in the park of Schönbrunn during a windy day in October. I was impressed with the antiquely furnished imperial apartment, the Sissi Museum and the silver collection of the Hofburg Palace. I was also speechless to see all the paintings by pioneering expressionists, such as Klimt, Schiele and Kokoschka at the beautiful palace of the Belvedere. I attended an Edvard Munch exhibition hosted by the Albertina Museum. It was also in Vienna that I attended my first opera.

During this visit, I witnessed that neurology or neuroscience is a fast-growing field, and each of us from different parts of the world can contribute a lot. I had only slight difficulties with the language barrier, and even then someone was always beside me to help. People were kind enough to try their best to communicate in English. Even though the duration of the stay seemed short, it is enough to meet the goal of the observership program. However, I believe the program to be so important that I suggest the number of young neurologists sponsored should be increased.

As a recommendation, I think the WFN can also think about exchange programs, whereby neurologists from developed countries pay a visit to African institutes and we can share our experiences. It is my hope that this program will continue and flourish in the future. It is encouraging and inspiring to young neurologists. It will also open a door for future collaborations and joint research projects.

In general, I can say with confidence that this program is successfully fulfilling its goal of fostering global neurological education.