In this page:

Section 1: Information about the writer

Ahmed Abbas – ST5 in Clinical Neurophysiology.

Queen Elizabeth Hospital Birmingham.

Section 2: Scope of practice in the UK:

Clinical Neurophysiology is a diagnostic specialty which concerns itself with investigating the function of the nervous system. It is allied to neurology and the neurosciences.

It deals with all age groups ranging from premature neonates to centenarians, and there is close collaboration with many specialties but particularly neurology, neurosurgery, orthopaedics, paediatrics and medical ophthalmology.

As implied by the name clinical neurophysiology, it is a clinical as well as diagnostic specialty. Therefore, central to the philosophy of this field is that it may be thought of as an extension of the standard clinical evaluation (i.e. history and physical examination), which aids in confirming, refuting or refining different diagnostic hypotheses.

Consider for example a patient referred to my clinic with a right foot drop. This same patient could either have a right L5 radiculopathy (e.g. disc disease), lumbosacral plexopathy (e.g. infiltrative tumour), sciatic neuropathy (e.g. nerve infarction) or common peroneal neuropathy (e.g. fibular neck compression). I would take a history and perform a targeted neurological examination and appropriate neurophysiological studies to localise the lesion at the correct level. Now assume that same patient with right foot drop had denied any sensory symptoms (which is usually expected in the previously listed aetiologies), and there were further subtle hints in my history and neurological examination which led me to suspect a more widespread neurological problem. I may then extend my neurophysiological assessment and garner evidence for example pointing towards a completely different diagnosis e.g. motor neuron disease, and so forth.

There are broadly three main techniques used by clinical neurophysiologists, all of which rely on the recording of bioelectrical signals arising from the nervous system.

Nerve Conduction Studies (NCS) and Needle Electromyography (EMG)

These are used to investigate all levels of the peripheral nervous system ranging from the anterior horn cells and nerve roots to the neuromuscular junction and muscles. Clinical neurophysiologists spend about half of their working time performing these practical procedures in direct contact with patients. In most centres, our fellow healthcare scientist colleagues can perform NCS for conditions such as suspected carpal tunnel syndrome, ulnar neuropathy or peripheral neuropathy. However EMG is only performed by medically trained staff.

Electroencephalography (EEG)

This is primarily used when looking for evidence to support a clinical suspicion of either epilepsy or, somewhat paradoxically, non-epileptic attack disorders. There are further applications such as in helping to subclassify the many different epilepsy syndromes e.g. juvenile myoclonic epilepsy, mesial temporal lobe epilepsy. This has important implications on treatment and prognosis. Standard EEG may also be used to assess cortical function (e.g. does this inpatient with hepatic cirrhosis awaiting a liver transplant have evidence of subclinical encephalopathy)? As a clinical neurophysiologist, you will interpret the EEGs that have been recorded by healthcare scientist colleagues and provide a clinical opinion in your report.

Evoked Potentials (EP)

These are primarily used to assess different central conduction pathways and include somatosensory evoked potentials (SSEPs – e.g. assessment of spinal cord in transverse myelitis), visual evoked potentials (VEPs – e.g. investigating optic neuritis in multiple sclerosis) and brainstem auditory evoked potentials (BAEPs – e.g. acoustic neuromas). As a clinical neurophysiologist, you will interpret the EPs that have been recorded by healthcare scientist colleagues and provide a clinical opinion in your report.

The above tools, which cover the bread and butter of the specialty, are used by all clinical neurophysiologists. In addition, there are more advanced or specialised applications of each of these techniques (see below; Section 4: sub-specialties)

Section 3: Type of Training/ Route to Training:

The duration of specialist training is four years, starting at ST3, of which one is spent gaining experience of neurology at registrar level. There is currently no exit exam, but this could change in the near future.

It is important to consider that in the UK, unlike most other countries, clinical neurophysiology is considered as a distinct specialty in its own right i.e. practiced by dedicated clinical neurophysiologists. For example in the USA, EEGs are interpreted by neurologists with an interest in epilepsy and who would have completed a subspecialty epilepsy fellowship. NCS/EMGs on the other hand are performed by neurologists who would have completed a subspecialty fellowship in neuromuscular disorders. This is an important point to bear in mind if you think you may want to practice in future as a consultant outside the UK.

If you do wish to practice as a consultant in both specialties, there are a minority of training programmes that offer dual accreditation in clinical neurophysiology and neurology. Alternatively you could first obtain a CCT in one specialty (usually neurology) and then apply separately to complete training in the other specialty (usually neurophysiology; in this case two years rather than four).

Like other medical specialties, you are encouraged to take time out to pursue research if you have particular academic interests.

 

Section 4: Sub-Specialties

As a registrar, there is a requirement to develop expertise in at least 1 advanced neurophysiological technique from each of EEG, EMG or EP – depending on your particular interests. This means that the job plans of consultant neurophysiologists can vary quite significantly depending on their particular interests and local needs (e.g. intraoperative neurosurgery monitoring vs visual electrophysiology reporting).

EEG

  • Long-term EEG monitoring (i.e. ambulatory or video EEG telemetry e.g. pre-epilepsy surgery work up).
  • Support for epilepsy neurosurgery (e.g. acute electrocorticograms and sub-acute intracranial electrode recordings, functional mapping of the brain).
  • Polysomnography and multiple sleep latency tests.

 

EMG

  • Single-fibre EMG (useful in disorders of the neuromuscular junction e.g. myasthenia gravis)
  • EMG-guided botulinum toxin therapy injection
  • Quantitative sensory testing

 

Evoked Potentials

  • Somatosensory evoked potentials (SSEPs) and motor evoked potentials (MEPs) e.g. intra-operative cord monitoring of spinal surgery.
  • Brainstem auditory evoked potentials
  • Electroretinography and electrooculography.

Section 5: Application Process:

Entry into the specialty requires successful completion of either CMT, ACCS or level 1 training in core paediatrics (Full MRCP or MRCPCH is required by the set deadline as specified in the person specification).

Section 6: Requirements To Get Into Training (Person Specification):

Please see the person specification through this link:

http://specialtytraining.hee.nhs.uk/files/2015/10/2016-PS-Clinical-Neurophysiology-ST3-1.0.pdf

Section 7: Important CV/Portfolio Perks (How To Achieve Them):

Again it would be worth looking at the desirable criteria outlined in the person specification (see Section 6). Adapt some of the generic stuff mentioned elsewhere on this site (e.g. audit) into relevant areas, e.g. an epilepsy related audit.

Generally I would think neurology experience at SHO level is advantageous.

If you are interested in clinical neurophysiology, it would definitely be worth spending a taster period shadowing the consultants and healthcare scientists in a neurophysiology department. This is important, not only to “tick the box” of showing interest, but also to get a feel for yourself of what neurophysiologists actually do in practice. This is sometimes a bit of a mystery to our colleagues. If nothing else, you’ll come away from the taster with wonderful memories of plenty of squiggly lines. We do like squiggly lines in clinical neurophysiology.

You could also demonstrate interest by attending meetings held by relevant societies e.g. British Society for Clinical Neurophysiology (BSCN) or British Peripheral Nerve Society (BPNS).

Ask your local neurologists if they have an interesting neuromuscular case that they think might be publishable.

Section 8: The Interview:

This is a national process. All applicants are interviewed in Sheffield. There are 3 stations. A detailed official description of the stations and what you can expect in each one is easily found under the “interview and scoring” tab of the following website:

http://www.st3recruitment.org.uk/specialties/clinical-neurophysiology

I will just outline a few points regarding the clinical station, as this is one that you can prepare for easily enough. You will be faced with a neurological scenario of sorts and asked questions about the case e.g. what further information do you want to know in the history, what are you looking for in the examination, how will you investigate and how will you treat?

quick-tip-e1366327676423I would personally suggest you brush up on neurology in general, and focus especially on topics that are of high relevance to clinical neurophysiology e.g. epilepsy (including emergencies: status epilepticus and non-convulsive status epilepticus [NCSE]), motor neuron disease, peripheral neuropathy (including emergencies e.g. : Guillain-Barré syndrome), myasthenia gravis (including emergencies e.g. : myasthenic crisis) myopathy (including emergencies: e.g. acute dermatomyositis) etc…

 

They will NOT reasonably expect you to know the technicalities of the neurophysiological techniques relevant to that scenario, but you will impress by demonstrating even a basic level of awareness that you may have picked up say in your taster period. So if it is a case of possible motor neuron disease you could say that you were looking for widespread evidence of denervation on needle EMG in the form of fibrillation potentials, positive sharp waves or fasciculation potentials in accordance with the Awaji critera. If it is a case of epilepsy, you should be at least superficially familiar with some of the EEG lingo and what it means e.g. inter-ictal sharp waves, spikes etc…

When preparing for the interview, follow the advice given in the link above (e.g. familiarise yourself with GMC Good Medical Practice etc…).

Section 9: Competition Ratio:

To be continued

Section 10: Offers and Visa Issues and HEE

To be continued

Section 11: Speciality Exams

To be continued

Section 12: Speciality Courses/Societies

To be continued

Section 13: Rotations

To be continued

Section 14: Ranking of Deaneries

To be continued

Section 15: Wages / Take Home Cash

To be continued

Section 16: MTI

To be continued

Section 17: Experience of Sudanese Doctors:

This is a small specialty. Across the UK there are just over 100 consultants and 30 trainees in the field. At present, there are excellent opportunities for obtaining consultant posts.

I was fortunate enough to complete a neurology rotation during my CMT which is where I was first properly exposed to clinical neurophysiology.

I enjoy this specialty for a number of reasons. Much of my working week is spent performing hands-on practical procedures, such as nerve conduction studies and EMG, in direct contact with a wide range of patients. There is a satisfying logic employed in interpreting neurophysiological techniques and this will appeal to individuals with problem-solving skills. I find neuroscience interesting and during my general medical training, I was always slightly more attracted to the diagnostic aspect of working a patient up than I was in their subsequent treatment, so clinical neurophysiology seemed a natural fit for me.

There is usually great camaraderie between clinical neurophysiologists and the wider healthcare scientist colleagues in a department. In addition to the daily intra-departmental team working, you also interact frequently with a wide range of referring clinicians which is rewarding in itself.

Most of the workload is outpatient-based. This lends itself to an excellent and rather civilised work-life balance. There are still plenty of inpatient studies to perform, however these are not arduous (like running a medical take) and are mostly accommodated within working hours. For example, only yesterday I performed NCS/EMG on an inpatient on the neurology ward which demonstrated an acute demyelinating polyneuropathy. In his clinical context and other investigations (including raised protein in an acellular CSF), the diagnosis fit with Guillain-Barré syndrome. When I returned to the neurophysiology department, over some freshly brewed Earl Grey tea and chocolate chip cookies, I reported several inpatient EEGs, one of which revealed non-convulsive status epilepticus in a patient on intensive care who was not waking up despite his sedation wean.

If the thought of repairing a ruptured aortic aneurysm in the middle of the night is very appealing to you, this is probably not your specialty! BUT don’t despair just yet. Assume said patient spends the next 5 weeks on ICU, having survived his aneurysm repair, and is discovered to be profoundly globally weak. If the thought of now diagnosing critical illness polyneuropathy or myopathy is more appealing to you, consider a taster week in clinical neurophysiology!

Anyway, thank you again for asking me to write about my specialty. I hope this helps “demystify” to an extent what clinical neurophysiology involves.

Section 18: Important Links and Websites

To be continued..

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Although the information contained on this guide should be fairly accurate, and every effort has been made to check Its details. However, it is possible that some errors have been missed or that some information may have been revised. The information provided by this website are believed to be true and accurate at the date of publication.