Abstract
Management of multiple sclerosis and neuroimmunologic disorders has become increasingly complex because of the expanding number of recognized neuroimmune disorders, increased number of therapeutic options, and multidisciplinary care management needs of people with multiple sclerosis and neuroimmunologic disorders. More subspecialists are needed to optimize care of these patients, and many fellowship programs have been created or expanded to increase the subspecialty workforce. Consequently, defining the scope and standardizing fellowship training is essential to ensure that trainees receive high-quality training. A workgroup was created to develop a consensus fellowship curriculum to serve as a resource for all current and future training programs. This curriculum may also serve as a basis for future accreditation efforts.
The American Academy of Neurology (AAN) Multiple Sclerosis (MS) Section Education Subcommittee is committed to ensuring high-quality training and educational opportunities for trainees across the discipline of neuroimmunology (NI). Surveys of current trainees, recent graduates, and fellowship program directors found that standardization of fellowship education was needed and widely supported.1,2 Therefore, a working group was established with representation from fellowship directors from diverse institutions, the National MS Society, the Consortium of MS Centers, the Veterans Affairs MS Centers of Excellence, and the Americas Committee on Treatment and Research in MS to jointly define the scope of MS and NI subspecialty training and develop a curriculum to ensure graduate competence across a standardized set of diagnoses and related topics.
MS and NI Subspecialty
Rationale for Subspecialty Expertise
MS is an immune-mediated neurodegenerative disorder directly affecting nearly 1 million people in the United States and 2.8 million worldwide.3,4 Specialized expertise is needed to ensure accurate diagnosis and optimal disease management.5,6 Delays in diagnosis and treatment initiation can result in cumulative and irreversible disability, although misdiagnosing MS exposes patients to inappropriate treatments and creates physical/psychological suffering.7
There has been a substantial expansion in the characterization of many non-MS immune conditions affecting the CNS, including neuromyelitis optica spectrum disorders (NMOSDs), antimyelin oligodendrocyte glycoprotein (MOG)-associated disorders (MOGADs), autoimmune encephalopathies, CNS vasculitis, and CNS complications of systemic autoimmune diseases. These complex disorders also require specialty training to diagnose accurately and treat expediently.
MS and other NI disorders (NIDs) often require systemic disease-modifying therapies (DMTs) that modulate and/or suppress the immune system function. Appropriate use and individualized DMT selection require substantial DMT mechanistic knowledge and a subspecialized skillset to craft treatment approaches and monitor adverse effects.
Finally, general neurologists find it increasingly difficult to provide optimal care for people living with MS and NID including management of day-to-day symptoms and psychosocial sequelae.8,9 Unfortunately, there are not enough MS and NI subspecialists available, and anticipated shortages in the future workforce compound the problem.10 As demand for specialists increases, MS and NI fellowship training programs have been created or expanded. There are currently 69 MS and NI fellowship programs in the United States.1 The subspecialty has not sought accreditation previously; however, there is growing interest among training programs (J.D., AAN MS Section Chair 2018–2020, personal communication, January 2020).
Proposed Definition/Scope of Subspecialty
NID broadly intersect many disciplines. At a minimum, an MS and NI specialist should be able to diagnose, differentiate, and treat MS, NMOSD, MOGAD, optic neuritis, and myelitis; be an expert in the appropriate use of immunotherapies and symptomatic management; and translate this expertise to care for patients within the ever-broadening realm of NID. The evolving spectrum of NID underscores the urgent need to define the scope of the subspecialty and standardize curricula to ensure that graduates acquire a common foundation and promote optimal care for people with MS and NID.
Goals of MS and NI Fellowship Training
The overall goals of the MS and NI Fellowship Curriculum are to:
Educate trainees in the pathogenesis of MS and NID and distinguish the immunologic differences.
Equip trainees to clinically diagnose and classify MS and NID and to differentiate these from mimics.
Equip trainees to identify, use, and interpret biomarkers used for the diagnosis and monitoring of MS and NID.
Educate trainees on the best use of DMTs for MS and NID, including understanding mechanism of action(s), identifying appropriate treatment strategies, and monitoring the efficacy, tolerability, and safety of DMTs.
Enable trainees to provide the highest quality of care to every patient, regardless of race, ethnicity, cultural background, or literacy by promoting cultural sensitivity and awareness of vulnerable populations.
Enable trainees to participate in comprehensive multidisciplinary care of people with MS and NID during training and to empower trainees to develop collaborative multidisciplinary teams in their future practice.
Background Training Requirements
Trainees will have completed a neurology residency in a program accredited by the Accreditation Council for Graduate Medical Education (ACGME) and be board eligible/board certified in neurology or neurology with special certification in child neurology by the American Board of Psychiatry and Neurology. Healthcare providers in, for example, physical medicine and rehabilitation, health psychology, and neuropsychology also might have interest in specialized training in MS and NID. A description of advanced training for those disciplines is beyond the scope of this study.
Training Tracks and Duration
MS and NI specialists practice in diverse settings with approximately 68%–75% of recent graduates practicing in academic centers.2 Owing to the heterogeneous career opportunities, subspecialty training has historically varied in duration and scope because trainees incorporate research activities and acquire complementary skills. This flexibility allows for individual tailoring, is a strength of the subspecialty, and must be preserved. Nevertheless, training can be broadly classified into clinical and clinical research tracks (table 1). Specific objectives for research tracks are beyond the scope of this study. Fellows in either track may choose to concurrently pursue relevant graduate coursework which may culminate in a master's degree.
Training Tracks
Training Environment
The primary training environment for MS and NI fellowships should be in a dedicated outpatient setting specializing in the care of people with MS and NID. Such clinics should feature multidisciplinary healthcare teams to ensure comprehensive disease management. Fellows should be equipped with the knowledge and skills necessary to manage relapses and other acute issues in the outpatient setting wherever appropriate. Because MS and NID are also treated in hospital settings, fellows should gain expertise in the breadth of acute diagnostic evaluations and hospital care management.
Because programs vary in the number and diversity of NI conditions evaluated, all fellows will not have the same opportunities to care for patients with these conditions. Supplementary didactic education should be used to ensure that trainees are familiar with the breadth and depth of rare NI conditions.
Recommended Core Competencies and Learning Objectives
The MS and NI fellowship is designed to prepare trainees for a subspecialty career providing comprehensive care for people with MS and NID. Direct patient care should be balanced with formal didactics and supplemented with electives. Fellows should be evaluated according to the AGCME core competencies (patient care, medical knowledge, practice-based learning and improvement, interpersonal and communication skills, professionalism, and systems-based practice). The core learning objectives are presented in table 2, with expanded details in table e-1 (links.lww.com/CPJ/A244).
Competencies and Learning Objectives: General Clinical Approach (Brief)a
Clinical evaluation skills of history and neurologic examinations should be acquired during residency and will be further developed toward aspects relevant to the care of MS and NID during fellowship. The fellow should be familiar with both contemporary and historical diagnostic criteria for MS and NID to accurately diagnose, recognize unusual presentations, and identify red flags indicating alternate diagnoses. Fellows must acquire specialized knowledge of diagnostic testing, immunomodulatory therapies, symptomatic treatments (pharmacologic and nonpharmacological), and learn to work effectively with an interdisciplinary team to provide comprehensive care for people with MS and NID. Finally, fellows must develop professionalism, a commitment to lifelong learning, and become stewards for the future of the MS and NI subspecialty. Fellows should have ample opportunities during training to demonstrate their skills. These could include fellow led conferences, teaching opportunities, and engagement with professional subspecialty organizations.
As the MS and NI subspecialty continues to expand, practitioners need to be aware of core NID listed in table 3. In addition, the MS and NI subspecialist needs to be aware of non-NI disorders that may influence diagnosis and management, have common neurodegenerative processes, or can present as mimics (table 3).
Learning Objectives: Core MS and NID and Relevant Non-neuroimmunologic Diseases
Electives
Multidisciplinary elective opportunities should be tailored to the trainee's educational needs and career goals. These might include neuroradiology, neuro-ophthalmology, rehabilitation (including spasticity management, gait and mobility, and cognitive), neurourology, neuroinfectious diseases, mental health, neuropsychology, rheumatology, and others.1
Trainee Evaluation
Trainees should be formally evaluated at least semiannually and provided feedback at regular intervals. The assessments should incorporate written 360-degree feedback from patients/caregivers and nonphysician staff following the model of ACGME core competencies. In addition, faculty evaluations will include fund of knowledge, basic clinical competence, and skills specific to MS and NID. Strengths and weakness should be used to tailor the trainee's education. A summary and final evaluation should be prepared by the program director and should reflect interval evaluations.
Conclusions
There is an unmet need for MS and NI subspecialists who are familiar with the subtleties of these disorders, the complexity of therapeutic choices, and the need to incorporate multidisciplinary care. With the increasing number and expansion of training programs in the field, a standardized curriculum will ensure that all trainees share basic competencies and are able to identify and manage rare syndromes after graduation. Development of shared resources including a national fellowship didactic program may ensure all programs can meet these requirements. We have developed this curriculum to reflect current needs, allow for future growth, and serve as a resource for all current fellowship training programs to implement easily. This consensus curriculum could serve as a basis for future accreditation of MS and NI training programs and provide a framework for one possible path toward subspecialty certification.
Study Funding
No targeted funding reported.
Disclosure
L.H. Hua reports personal compensation for speaking, consulting or advisory board activities from Biogen, Genzyme, Novartis, Bristol Myers Squibb, Genentech, Viela Bio, and EMD Serono. A.Z. Obeidat reports personal compensation for consulting, speaking or serving on steering committees or advisory boards for Genzyme, Biogen, Novartis, Alexion Pharmaceuticals, Genentech, EMD Serono, Bristol Myers Squibb, Research support from the Center for Immunology, Research Affairs Committee and Neuroscience Research Center at the Medical College of Wisconsin, and serving on the editorial board of the International Journal of MS Care. L. Amezcua reports personal compensation for consulting, speaking, or serving on steering committees or advisory boards for Biogen Idec, Novartis, Alexion Pharmaceuticals, Genentech, EMD Serono and AbbVie; and research support from the National MS Society, NIH NINDS, and Biogen Idec. J.A. Cohen reports personal compensation for consulting for Adamas, Atara, Bristol-Myers Squibb, Convelo, MedDay, and Mylan; and serving as an Editor of Multiple Sclerosis Journal. K. Costello reports no personal disclosures. The National MS Society receives funding from Acorda, Bayer, Biogen, Celgene, EMD Serono, Genentech, Mallinckrodt, Mylan, Novartis, Sanofi Genzyme and Teva for Events, Programs and Healthcare Access initiatives. J. Dunn reports personal compensation for consulting or lectures from Bristol Myers Squibb, Alexion, Novartis, Genzyme and Roche Genentech, and scientific advisory board for Progentec Diagnostics, Inc. Patent holder, USPTO # 10054588, for marker of MS treatment responsiveness. J.M. Gelfand reports personal compensation for consulting for Biogen and Alexion, research support from Genentech/Roche to UCSF for a clinical trial; and personal compensation for medical-legal consulting. M.D. Goldman reports personal compensation for consulting from ADAMAS Pharmaceuticals, Biogen IDEC, Brainstorm Cell Therapeutics Ltd., EMD Serono, Genetec, Greenwich Biosciences, Immunic, MedDay, and Sanofi Genzyme. S. Hopkins reports salary support from CDC for activities related to AFM surveillance and site PI for the NIH/NIAID AFM Natural History Study. D. Jeffery reports honoraria for speaking and consulting for Bayer, Biogen, Teva, Serono, Pfizer, Novartis, Genzyme, Genentech, and Mallinckrodt. S. Krieger reports consulting or advisory work with Biogen, EMD Serono, Genentech, Genzyme, Mallinckrodt, MedDay, Novartis, Teva, and TG Therapeutics, and non-promotional speaking with Biogen, EMD Serono, Genentech, and Novartis; and grant and research support from Biogen and Novartis. S.D. Newsome reports personal compensation for consulting for scientific advisory boards from Biogen, Genentech, Celgene, EMD Serono, Novartis, is an advisor for BioIncept and Autobahn, a clinical adjudication committee member for a MedDay Pharmaceuticals clinical trial and has received research funding (paid directly to institution) from Biogen, Novartis, Genentech, National Multiple Sclerosis Society, Department of Defense, and Patient Centered Outcomes Institute. S. Shah reports compensation for advisory board with Biogen. N.L. Sicotte reports research support from Biogen-Idec, PCORI, and NIH U01NS116776. Vijayshree Yadav reports personal compensation for consulting from Alexion and EMD Serono, and research support from the Department of Veterans Affairs, Patient Centered Outcomes Research Institute, National Institute of Health, National MS Society and Tykeson Foundation. E.E. Longbrake reports personal compensation for consulting for Biogen, Bristol Myers Squibb, Genentech, Alexion, Genzyme, EMD Serono; and research support from the Race to Erase MS and NIH K23NS107624. Full disclosure form information provided by the authors is available with the full text of this article at Neurology.org/cp.
Appendix Authors
Footnotes
Funding information and disclosures are provided at the end of the article. Full disclosure form information provided by the authors is available with the full text of this article at Neurology.org/cp.
- Received July 17, 2020.
- Accepted November 16, 2020.
- Copyright © 2021 American Academy of Neurology
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