Neurology Consultation Service
Inpatient Behavioral Neurology Consult Service: History
One hundred ninety years ago, Benjamin Rush wrote to John Adams, "[the diseases of the mind] have hitherto been enveloped in mystery ... I have endeavored to bring them down to the level of all other diseases of the human body and to show that the mind and body are moved by the same causes and subject to the same laws." This concept of an integrated approach to mind, brain, and behavior was shared by the forefathers of clinical brain sciences, including Freud, Kraepelin, Charcot, Alzheimer, Brueler, and others. Sigmund Freud, the founder of psychoanalysis, was formally trained as a neurologist. Alois Alzheimer, who described a dementing disorder subsequently named after him, was educated as a psychiatrist and neuropathologist.
Historically, practitioners were trained in both neurology and psychiatry; they were "neuropsychiatrists" committed to the study of the biologic substrates of brain disease. However, a division began to occur when neurology concentrated on those diseases of the nervous system that were pathologically verifiable, while psychiatry approached those diseases that were not. In this vacuum, the ascendance of psychoanalysis occurred with virtual abandonment by Freudâ€™s followers of efforts to explain cognition and behavior in biologic terms. The rift developed further between neurology and some elements of psychological psychiatry due to inadequate scientific sophistication and lack of knowledge. This resulted in an over-reliance on normal psychology to explain serious psychopathology and a disinclination to focus in any important way on the biological basis of behavior.
While last century's neuropsychiatrists recognized that mind and brain were inseparable, most diseases of the brain could not be visualized, measured, or readily repaired. Recent advances in neuroscience have illuminated anatomic, cellular, and molecular substrates of psychiatric disease. The pathophysiologic basis of many illnesses are beginning to be empirically identified and many can now be characterized microscopically. Moreover, amelioration of disease with pharmacologic and psychotherapeutic treatment is approaching quantifiable measures. Once again, the mind and brain are recognized as inseparable. The traditional boundaries separating psychiatry and neurology are becoming increasingly indistinct. The education of brain clinicians should therefore be restructured to reflect these fundamental changes. We offer one such model that attempts to promote this necessary coalescence.
Rounds with the Neuropsychiatry and Behavioral Neurology (NBN) Inpatient Consult Service
In 1994 the Neuropsychiatry and Behavioral Neurology (NBN) consult service began as an academic forum bringing together neurologists, psychiatrists, and neuropsychologists in the same setting to formulate diagnoses and treatment plans for clinically challenging inpatients. The NBN service was inspired by a prior model, the Beth Israel Behavioral Neurology Program, as pioneered by Dr. Norman Geschwind, and under whom the founder of the NBN service trained (BHP). Collaborations such as these serve many functions. They dismantle perceived barriers between the disciplines. They serve as a free interchange of knowledge and techniques between the disciplines, contributing new clinical insights and tools to each of its specialists. They become the setting for rich "cross-training" for medical students, residents, and fellows. And they offer enhanced service to the patients and their treatment teams by providing coordinated insight and recommendations for difficult clinical problems.
We therefore offer a model that has been sculpted over a number of years - accompanied by increasing knowledge in neuropathoetiology and promotion of the dissolution of traditional boundaries separating mind/brain disciplines. Our supposition is that medical education, developments in neuroscience, and the delivery of high quality care to patients must continue to develop synergistically and in parallel.
The structure of the McLean NBN consult service is based on a multi-tiered system of collegial interaction consisting of attendings, fellows, residents, and medical students. Senior staff neurologists, psychiatrists, and neuropsychologists participate as clinician-mentors. A two-year fellowship in neuropsychology, funded by clinical income, was initiated in 1995. A privately funded one or two-year fellowship in behavioral neurology and neuropsychiatry was started in 1999. Psychiatry residents from internal and external programs rotate through the NBN service for one or two months to satisfy their two-month neurology requirement as set by the Residency Review Committee for Psychiatry and Neurology. Neurology residents electively rotate for one-month intervals. Harvard medical students participate one day per week during their psychiatry rotation at McLean Hospital.