Agnieszka A. Ardelt

James R. Brorson

Rimas Vincas Lukas

Trent Steelsmith Hodgson

PubMed

Trent S. Hodgson

Rimas V. Lukas

Frontiers - Publisher Connector

creation of a UCNS Neurocritical Care 
 certification in 2007 affected the neurology 
community’s perception of Neurocritical 
Care as a subspecialty distinct from Vascular 
Neurology and General Neurology. Here 
we present data that the accreditation of 
Vascular Neurology and Neurocritical Care 
fellowships appears to have accelerated the 
divergence of these subspecialties.
ABPN ANd UCNS diPlomAteS
Analysis of publicly available lists of 
Vascular Neurology diplomates from the 
ABPN and Neurocritical Care diplomates 
from the UCNS can provide a clearer 
understanding of subspecialization trends 
in Neurology. Both lists include the full legal 
name, degrees held, and city of residence 
at the time of certification. This allows 
for determination of which diplomates 
received both certifications. Of note, these 
lists include only those who have passed the 
iNtrodUCtioN
In the 2011 American Academy of Neurology 
Residents Survey 86% of American neurol-
ogy residents planned to complete a fellow-
ship after their residency, up from estimates 
of 78% in 2008 and 74% in 1996 (1–3). There 
has been an increase in the types of subspe-
cialty fellowship programs and, importantly, 
the available certifications. To understand the 
impact of this increasing accreditation one 
can compare two fields that overlap in the 
care of patients with acute ischemic or hem-
orrhagic stroke: Vascular Neurology, which is 
certified by the American Board of Psychiatry 
and Neurology (ABPN), and Neurocritical 
Care, which is certified by the United Council 
for Neurologic Subspecialties (UCNS).
Within the United States and Canada, the 
ABPN and UCNS are the primary accredit-
ing bodies of neurology fellowships. These 
organizations accredit fellowship pro-
grams that have applied and met prede-
termined standards. They also create their 
own exams and administer certification to 
qualified physicians who pass. The ABPN 
was founded in 1934 and the UCNS was 
founded in 2003 (Table A1 in Appendix). 
The organizations have similarities, but one 
difference is the UCNS’s interest in serving 
small subspecialties (4). This is significant 
for emerging subspecialties within neurol-
ogy as the importance assigned to physician 
certifications by patients, employers, and 
other physicians will likely continue to grow.
Changes in education and accreditation 
often occur after changes in practice have 
already occurred. Neurocritical Care has 
emerged as a new subspecialty over the past 
30 years based on perceptions and evidence 
that neurologists with expertise in this area 
improved patient care (5). Fellowships 
in Neurocritical Care have existed for a 
number of years, but it is unclear how the 
exam and received  certification, not those 
who sat for the exam but did not pass. The 
UCNS does not publish passing rates, but 
the ABPN reports between 92.3 and 94.7% 
passing from 2008 to 2011.
VASCUlAr NeUrology ANd 
NeUroCritiCAl CAre
The ABPN first issued certifications in 
Vascular Neurology in 2005 and the 
UCNS began issuing Neurocritical Care 
certifications in 2007 (Figure 1). In their 
inaugural years, there were 234 Vascular 
Neurology diplomates compared to 91 
Neurocritical Care diplomates. Through 
2011, 1098 ABPN Vascular Neurology cer-
tifications have been issued and publically 
listed, almost twice as many as the 554 
UCNS Neurocritical Care certifications. 
The flat sections in the  cumulative totals 
 demonstrate that both exams are offered 
only 2 out of every 3 years.
Accrediting neurology fellowships accelerates 
subspecialization
Trent S. Hodgson1, James R. Brorson2, Agnieszka A. Ardelt2,3 and Rimas V. Lukas2*
1 Pritzker School of Medicine, University of Chicago, Chicago, IL, USA
2 Department of Neurology, University of Chicago, Chicago, IL, USA
3 Section of Neurosurgery, Department of Surgery, University of Chicago, Chicago, IL, USA
*Correspondence: rlukas@neurology.bsd.uchicago.edu
Edited by:
Jagjit Singh Chopra, Postgraduate Institute of Medical Education and Research, India
Keywords: education, neurology, fellowships, certification, accreditation, neurocritical care, vascular neurology, subspecialization
Figure 1 |  Cumulative number of diplomates by year and certification(s) held. NCC, Neurocritical Care.
www.frontiersin.org July 2013 | Volume 4 | Article 94 | 1
OpiniOn article
published: 23 July 2013
doi: 10.3389/fneur.2013.00094
The percentage of individuals who hold 
both certifications was initially high but has 
since declined (Figure A1 in Appendix). Of 
the 91 physicians who received their UCNS 
Neurocritical Care certification in 2007, 60 
(65.9%) have also received ABPN certifica-
tion in Vascular Neurology. This is signifi-
cantly more than the 20 out of 165 UCNS 
Neurocritical Care diplomates (12.1%) 
in 2011 that also hold ABPN Vascular 
Neurology certification (p < 0.001).
In addition, fewer physicians are going 
on to obtain their ABPN Vascular Neurology 
certification after they have received UCNS 
Neurocritical Care certification (Figure A2 
in Appendix). Of those with both certifica-
tions, 61.7% of 2007 UCNS Neurocritical 
Care diplomates went on to obtain their 
ABPN Vascular Neurology certification in 
the same calendar year or later than their 
UCNS Neurocritical Care certification. This 
decreased to 35.0% of 2011 UCNS diplo-
mates (2007 vs. 2011, p = 0.01).
diSCUSSioN
The practice of Neurocritical Care has 
defined itself over the past several decades. 
This differentiation is a gradual, ongoing 
process led by changes in clinical realities, 
technical advances, and a dedicated journal 
(6, 7). In addition to these primary influ-
ences, we present evidence that UCNS cer-
tification of preexisting Neurocritical Care 
fellowships may have accelerated the sub-
specialization of Neurocritical Care.
Multiple factors contribute to nearly twice 
as many ABPN Vascular Neurology certifica-
tions as UCNS Neurocritical Care certifica-
tions being issued to date. The practice of 
Vascular Neurology is older, taught in every 
residency, and more exclusively the realm 
of neurologists. Of the 7188 practicing US 
neurologists who responded to the 2008 
American Academy of Neurology  census, 
37.0% selected cerebrovascular disease as an 
area of practice focus compared to 9.2% who 
listed critical care. Thus, it would be expected 
that there is a higher absolute number of indi-
viduals practicing Vascular Neurology who 
would desire certification. Additionally, a sig-
nificant portion of neurology residents do not 
have required exposure to Neurocritical Care 
during their training and in turn may not seek 
additional training in this subspecialty.
Whatever the field’s initial interest, 
there was a substantial degree of overlap 
in individuals receiving both  certifications 
(65.9% of 2007 UCNS Neurocritical Care 
 diplomates). However, since 2007, the 
percentage of individuals holding both 
certifications decreased significantly as 
did the percentage of  individuals who 
went on to obtain their ABPN Vascular 
Neurology certificate the same year or 
later than their UCNS Neurocritical Care 
certification. This likely reflects the con-
tinued emergence of Neurocritical Care 
as a distinct subspecialty and may reflect 
the increased stature of the UCNS and its 
certifications.
The end of grandfathering periods, 
where qualified physicians who trained 
before accreditation was available are 
allowed to take the certification exam, 
will further impact the divergence of 
these subspecialties. The ABPN Vascular 
Neurology grandfathering period was 
from 2005 to 2009 and the UCNS certi-
fication in Neurocritical Care grandfa-
thering period is from 2007 to 2013. It 
would be expected that the proportion 
of diplomates with both certifications 
would decrease with the end of the ABPN 
Vascular Neurology grandfathering period 
in 2009. However, the rate of decline of 
individuals with both certifications as a 
proportion of all Neurocritical Care dip-
lomates before and after 2009 is similar 
suggesting that this alone cannot explain 
our observations.
FUtUre oF SUBSPeCiAlizAtioN
There are pros and cons to increasing sub-
specialization within neurology (8–11). 
Increased subspecialization can facilitate 
clinical and translational research as well 
as improved patient care. However it may 
artificially restrict the scope of practice of 
neurologists who already completed their 
training, trained in another subspecialty, 
or completed an unaccredited fellowship. 
The impact will likely vary between differ-
ent practice types, especially academic and 
non-academic settings. It will also depend 
on employers’ perception of the value of 
certification as well how certification, or the 
lack thereof, affects individual physicians’ 
comfort level practicing in the ICU.
It will be important to monitor both 
economic and geographic growth trends to 
better understand the impact of increasing 
accreditation of neurology fellowships. This 
data should then be used to prevent unin-
tended consequences such as  fragmentation 
of care, over-referral, and a  geographic 
maldistribution of  subspecialists. In this 
way, the decision to pursue fellowship 
training can be based on the desire to gain 
expertise that improves patient care more 
than any secondary gains.
CoNClUSioN
Accreditation of subspecialty training pro-
grams and certification of their graduates 
has served as a catalyst accelerating the 
ongoing subspecialization of Neurology. 
Our discussion of the progressive dif-
ferentiation of the related subspecialties 
of Vascular Neurology and Neurocritical 
Care supports this conclusion. While our 
discussion focused on fellowship training 
in the U.S. and Canada these trends are 
likely to influence neurology fellowship 
training throughout the world. Going 
forward, it is important to understand 
the impact of accreditation on patient 
care, reimbursements, and the neurology 
workforce and to use this knowledge to 
guide future decisions on accreditation. 
As any decision will carry benefits and 
drawbacks, accrediting bodies including 
the ABPN and UCNS should maintain a 
transparent process whose primary goal is 
to improve the treatment of patients with 
neurologic disease.
ACkNowledgmeNtS
We acknowledge the ABPN and UCNS for 
responding to our queries.
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Received: 01 July 2013; accepted: 05 July 2013; published 
online: 23 July 2013.
Citation: Hodgson TS, Brorson JR, Ardelt AA and Lukas 
RV (2013) Accrediting neurology fellowships accelerates 
subspecialization. Front. Neurol. 4:94. doi: 10.3389/
fneur.2013.00094
This article was submitted to Frontiers in Neurology 
Education, a specialty of Frontiers in Neurology.
Copyright © 2013 Hodgson, Brorson, Ardelt and Lukas. 
This is an open-access article distributed under the terms 
of the Creative Commons Attribution License, which 
 permits use, distribution and reproduction in other 
forums, provided the original authors and source are 
credited and subject to any copyright notices concerning 
any third-party graphics etc.
www.frontiersin.org July 2013 | Volume 4 | Article 94 | 3
Hodgson et al. Accreditation and subspecialization
APPeNdix
Table A1 | ABPN and uCNS specialties and subspecialties. The year each was initially accredited is 
listed in parentheses.
American Board of Psychiatry and 
Neurology
united Council for Neurologic 
Subspecialties
Founded 1934 2003
Primary certifications Psychiatry, Neurology, Child 
Neurology
n/a
Accredited 
subspecialties*
Clinical Neurophysiology (1989) Behavioral Neurology and 
Neuropsychiatry (2004)
Pain Medicine (1998) Clinical Neuromuscular Pathology (2005)
Neurodevelopmental Disabilities (1999) Headache Medicine (2005)
Vascular Neurology (2003) Neuro-Oncology (2005)
Neuromuscular Medicine (2005) Neuroimaging (2005)
Sleep Medicine (2005) Neurocritical Care (2005)
Hospice and Palliative Care (2006) Autonomic Disorders (2007)
Epilepsy (2011) Geriatric Neurology (2007)
Brain Injury Medicine (2011) Neural Repair and Rehabilitation (2010)
*Listed by year of approval, which is typically 2 years before the first exam is offered. Five ABPN Psychiatry-only 
subspecialties are not listed.
Figure A2 | Average number of years between receiving each certification in individuals with both 
certifications listed by year of uCNS certification. For each individual, the difference is calculated as year 
of ABPN certification minus year of UCNS certification. Error bars are ±1 SD.
Figure A1 | Cumulative percentage of uCNS diplomates who also hold ABPN Vascular Neurology 
certification by year of uCNS certification.
Frontiers in Neurology | Neurology Education  July 2013 | Volume 4 | Article 94 | 4
Hodgson et al. Accreditation and subspecialization


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