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The following is an outline of experiences during the postdoctoral fellowship program. This is a two-year Program, with the 24 months split between the Benton Neuropsychology Laboratory (16 months) and the Psychiatry Neuropsychology Service (8 months). Below, the specific training experiences are divided into activities related to clinical service, research, and education, although in practice these three domains are often blended. For example, a clinical conference is likely to lead to a discussion of the research literature on a given topic or condition. As noted earlier, our Program conforms to the guidelines of the Houston Conference, and is intended for highly motivated postdoctoral students who aim to establish a career in the practice and science of clinical neuropsychology. Fellows are formally evaluated by faculty every six months, and provided feedback regarding strengths and weaknesses so as to maximize the provision of training needs and interests. In addition, fellows take the APPCN Postdoctoral Examination at the end of their first year (see below). In broad terms, responsibilities can be broken down as follows:
Clinical activities comprise approximately 80% time during the first year. On average, first year fellows see 1-2 patients per day once they begin by completing evaluations with the assistance of psychometricians. Initially, patients are seen directly by the fellow. After demonstrating proficiency in neuropsychological test administration and scoring, fellows are taught to complete assessments with the aid of technicians (psychometricians) who complete the testing under the supervision of the fellow and a faculty neuropsychologist. Fellows receive considerable training and experience in supervising psychometricians in neuropsychological evaluations. Time is spent principally in diagnostic work. As fellows gain experience, there can be increasing involvement in the Rehabilitation Laboratory. Fellows are supervised by clinical faculty. A clinical faculty member supervises each case individually; there is no group supervision.
In the Benton Laboratory Rotation, a typical examination is comprised of approximately three hours of patient contact. Reports are concise. Fellows are taught, on a case-by-case basis, to identify core neuropsychological syndromes associated with different neurologic conditions, effective and concise report writing, and how to identify relevant demographic, historical, medical, and psychological information in developing a neuropsychological diagnosis (see Tranel, 2009 for a summary of the Benton Laboratory method). In the Psychiatry Neuropsychology Rotation, evaluations typically involve two to six hours of patient contact, depending upon the referral question and patient characteristics. In both rotations, once Fellows demonstrate proficiency in formal testing, they are responsible for clinical interviewing, test selection, psychometrician supervision, report writing, and providing verbal feedback in consultation with and under the supervision of faculty neuropsychologists.
The method of assessment derives from the tradition of Arthur Benton, following a hypothesis-based testing approach (Benton, 1994; Tranel, 2009). Fellows conduct examinations on diverse outpatient and inpatient populations with a variety of presenting conditions and referral questions, including neuropsychiatric disorders, dementia, traumatic brain injury, metabolic and other chronic health conditions, neurological disorders, and learning disorders/ADHD. Referral questions are diverse as well, including differential diagnosis, treatment and discharge planning, decision making capacity, and academic accommodations. Fellows are exposed to complex cases that often involve both neurological and psychiatric issues. The approach to evaluations places an emphasis on individual supervision, hypothesis testing, concise and rapid report writing, and clear verbal communication of results to patients, treatment teams, and referring providers.
The Benton Neuropsychology Laboratory and the Psychiatry Neuropsychology Service maintain registries of individuals representing different lesion sites and neuropsychological manifestations. In addition to access to patients with focal lesions, there are numerous opportunities to study patients with specific neurological and medical conditions (e.g., Alzheimer’s disease, Parkinson’s disease, TBI, neuropsychiatric disorders, temporal lobectomy). In the Benton Laboratory, patients who may be of special interest to research studies are identified daily in the outpatient clinics and in the inpatient Stroke Rounds and Morning Report. The availability of cooperative and well-studied patients has permitted a fundamental departure from the traditional orientation of neuropsychological studies: rather than studying interesting, isolated cases as they happen to occur, investigators are able to accrue and use extensive data about many neuropsychological and neuropsychiatric disorders. Moreover, for the past 30 years, all of the patients seen through the Benton Neuropsychology Laboratory have been coded and classified according to basic demographic information, neuropsychological syndrome (e.g., aphasia, amnesia, dementia) and neurologic disease (e.g., stroke, traumatic brain injury), permitting instant access to specific patient types. The neuropsychological data derived from assessment of these individuals are stored in permanent form and are available for research studies. Likewise, data from patients seen by the Psychiatry Neuropsychology Service are included in a database and fellows have access to these data for research purposes.
Research experience is initially provided through individual consultation with faculty, attendance at research seminars, and reading relevant textbooks and primary literature. Regular research meetings are attended by first year fellows, with the aim of developing an area of interest. These meetings are typically multidisciplinary, and include faculty neuropsychologists and neuroscientists, neurologists, neuropsychology technicians, psychology graduate students, neuroscience graduate students, and undergraduate students in psychology. In the latter half of the first year, fellows are encouraged to develop a research interest, to consult with faculty regarding specific projects, and to initiate such projects as appropriate.
The tradition of research excellence in the University of Iowa’s neuropsychology and cognitive neuroscience domains is hard to overstate. Carrying on the legacies of Arthur Benton and Antonio and Hanna Damasio, and capitalizing on a strong record of continuous NIH and private foundation funding, scientists in the Benton and Psychiatry services conduct cutting edge research in clinical and experimental neuropsychology. Fellows have many opportunities to become involved in ongoing projects, and to develop their own lines of investigation.
Early educational experiences include consulting with faculty regarding clinical cases, attendance at Neurology Grand Rounds, Stroke Rounds, Neuroscience Seminars, Benton Lectures, Psychiatry Grand Rounds, Neuropsychology Journal Club, and the Geriatric Journal Club. A core set of readings is provided at the outset of training, to provide fellows with fundamental knowledge and principles related to the practice of clinical neuropsychology, neuropsychological syndromes, common neurologic diseases, and current issues in professional clinical neuropsychology. Many of these activities overlap substantially with research or clinical interests of the group. Readings are provided on an individual basis, based on the fellow’s individual interests, strengths, and educational needs. Specific didactic classes or experiences may be arranged, depending on the interests and educational needs of the fellow. Optional venues for educational growth include formal coursework (e.g., graduate courses such as Functional Neuroanatomy; Principles of Neuropsychology; Topics in Cognitive Neuroscience; Neurobiology of Disease) and specialty rounds (e.g., Epilepsy Surgery Conference, Radiology Conference, Dementia Clinic meetings, Neurology and Neurosurgery Bed Rounds). Also, the program supports fellows to attend the annual meeting of the International Neuropsychological Society.
Fellows participate in a quarterly career development seminar series addressing professional issues relevant to the transition from fellow to independent professional. The seminar includes some lecture material, but is primarily discussion based. The seminar topics will be developed at the beginning of each year in conjunction with the fellows driven, in part, by the fellows’ professional goals. Topics may include the job application process, job negotiation, clinical billing and insurance, balancing professional and personal life, and mentoring skills. This seminar series is led by Dr. Hoth.
Following the first year of the fellowship program, fellows are administered the APPCN first-year test. This is 50-item, 4-alternative multiple choice test that assesses advanced knowledge in neuropsychological assessment and treatment, neuropsychological syndromes, and relevant neurological and psychiatric diseases. The general format of the exam is akin to the EPPP licensing exam and the ABPP/Cn board examination, with content specific to neuropsychology. Fellows are provided their score and feedback from the Program Director, and results are used to guide specific directions for second-year training.
The second year of the fellowship is considered a continuation of the first, and many of the same activities are continued. However, in general, there is a greater emphasis on research, on more complex cases, and on supervision of technicians and practicum students in clinical work. Greater independence in clinical activities is expected. Many second-year fellows participate in teaching, e.g., through presentations in Departmental Grand Rounds and morning Neuropsychology Rounds.
The clinical appointment is approximately 50-70% time during the second year, with the possibility of a focus on specific areas of interest (e.g., dementia, stroke, epilepsy, TBI). Also, opportunities for involvement in medical-legal assessment cases are provided, and fellows are able to observe depositions and court appearances by staff neuropsychologists. Fellows can expect to see approximately two cases per day, under the technician model. In addition, fellows often maintain a partial clinical load (e.g., 10%) in the Rehabilitation Laboratory.
Research activity typically takes on greater importance in the second year, comprising a greater proportion of the fellow’s time. For fellows with a strong research orientation, protected research time, free from clinical activities, is provided. This proportion can range up to nearly 50%, depending on interests, aptitude, and productivity. Fellows work closely with faculty members, and often submit completed research to relevant conferences and meetings (e.g., International Neuropsychological Society, Society for Neuroscience) and peer-reviewed journals. For fellows whose careers are aimed in a scientist-clinician direction, up to 50% time may be allotted for research endeavors.
Ongoing educational activities include attendance at Neuroscience Seminar, Benton Lectures, Neuropsychology Rounds, Neurology Grand Rounds, Psychiatry Grand Rounds, and numerous lectures, colloquia, and seminars offered in the Departments of Neurology and Psychiatry and elsewhere in the College of Medicine and the University. Additional educational activity at this level is dedicated primarily to research endeavors, although particular areas of interest or areas of relative weakness may be addressed through didactic and experiential education. The Program supports the cost of Fellows attending the annual meeting of the International Neuropsychological Society.
As core members of the UI Comprehensive Epilepsy Program, Benton Laboratory neuropsychologists conduct specialized “Phase I” evaluations of all candidates for resection surgery for treatment of pharmaco resistant epilepsy. The neuropsychological findings are presented at the multidisciplinary Epilepsy Surgical Case Conference, in which neuropsychology plays a central role in discussions regarding patients’ candidacy for surgical intervention. If candidacy advances, Benton Neuropsychology performs Wada testing to assess hemispheric contributions to language and memory. Approximately twenty Wada procedures per year are performed, with sequential injections of each hemisphere, typically with half-hour interval between injections.
A number of previous fellows have taken part in morning Stroke Rounds through the University of Iowa Stroke Center. Staffed by senior neurologists, Stroke Rounds are a unique venue for teaching both the medical and behavioral/cognitive effects of acute brain injury, and are attended by a number of students including residents, fellows, and medical students. This experience affords the opportunity to see interventions with acutely ill patients with focal brain lesions, learn about neurological examinations, and see behavioral syndromes that are typically only transient nature following an acute lesion (for example akinetic mutism or right hemispatial neglect).
Through cooperation with the Department of Neurosurgery, a number of previous fellows have attended brain surgery. Specifically, fellows have followed patients that they have seen for assessment through the process of surgery for medication resistant epilepsy. Such an experience provides the fellow with an appreciation of the full course of surgical treatment for pharmaco resistant epilepsy, beginning with the neuropsychological valuation, through specialized Wada testing, respective surgery, and follow up.
Carbon Monoxide Assessment
UIHC is the frontline treatment center in the state of Iowa for cases of moderate to severe carbon monoxide exposure to be sent for acute treatment in the hyperbaric oxygen chamber. By protocol, after hyperbaric treatment our service is consulted to assist with determination whether the patient is showing signs of persistent cerebral dysfunction (prompting additional hyperbaric treatment), and to conduct a standardized exam at one week and at six weeks to assess for possible delayed effects.
Huntington’s Disease Clinic
UIHC is designated as a Center of Excellence by the Huntington’s Disease Society of America, which allows fellows to participate in the interdisciplinary Huntington’s Disease (HD) Clinics during their rotations in the Psychiatry Department Neuropsychology Service. The HD Clinic interdisciplinary team consists of psychiatrists, neurologists, neuropsychologists, psychometricians, genetics counselors, social workers, and pharmacists. Fellows participate in neuropsychological evaluations and interdisciplinary team meetings during HD clinics. The HD Clinic coordinates the diagnosis, treatment, and counseling of individuals and families coping with Huntington’s disease or at risk for developing this disorder.
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