Where there is no resident neurologist: a case for a neurology attachment for acute medicine trainees

Acute neurological problems account for 15% of the general unselected medical take and where there are no resident neurologists, general physicians care for these.¹ In one third, the diagnosis remains uncertain or is inaccurate.² With the new acute medicine curriculum, there is limited scope for trainees to rotate outside the prescribed core specialties, and this is a potential training flaw.

The previous acute medicine specialist registrar rotation in Wales had a six-month ‘elective period’ for trainees to pursue other medical interests. One former acute medicine trainee (LA) spent two months of his ‘elective’ on attachment in a tertiary hospital neurology unit. The attachment included weekly participation at four outpatient clinics (neurovascular, epilepsy, rapid access and general neurology); neurophysiology and neuroradiology sessions, inpatient ward work and seeing urgent referrals from primary and secondary care. The case mix encountered is described in Table 1.

This experience has been invaluable in this former trainee's current role as a consultant acute physician, part of which is in the ambulatory care unit of a small district general hospital where, in eight months, 40% of the 730 patients seen were referred with a neurological problem. Of these, acute onset headaches were the biggest group (30%) and transient ischaemic attacks and first seizures accounted for 20% each. Of those presenting with acute onset headaches, the most common diagnosis (in one third of headache cases) was migraine.

Incorporating neurology into acute medicine training programmes is extremely useful. It helps the non-neurologist handle the immediate issues more confidently, and to refer appropriately. The increasing use of thrombolysis for acute stroke will only increase the demand for front-line clinicians who are confident in the diagnosis of acute neurological deficits.

• Royal College of Physicians