Fellowship Experiences

Program Experiences

The following is an outline of experiences during the two-year postdoctoral fellowship program in clinical neuropsychology.  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 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).

A. First Year Fellow Experiences

1. Clinical

Clinical activities comprise approximately 80% time during the first year.  On average, first year fellows see 1-2 patients per day once they begin completing evaluations with the assistance of psychometricians. Initially, testing of their patient is completed 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. However, there are various times when fellows are required to complete testing with patients. 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 Neuropsychology Clinic, 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 Neuropsychology Clinic method).  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. 

2. Research

The Benton Neuropsychology Clinic maintains a registry 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 Neuropsychology Clinic, 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 35 years, all of the patients seen through the Benton Neuropsychology Clinic 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. 

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 Clinic 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.

3. Education 

Early educational experiences include consulting with faculty regarding clinical cases, attendance at Neurology Grand Rounds, Stroke Rounds, Neuroscience Seminars, Benton Lectures, and Neuropsychology 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 Surgical Case Conference, Radiology Conference, Dementia Clinic meetings, Neurology and Neurosurgery Bed Rounds).  Also, as noted earlier, the Program supports fellows to attend the annual winter meeting of the International Neuropsychological Society, with compensation for travel, lodging, and meeting registration.

4. Examination

Following the first year of the fellowship program, fellows are administered the APPCN first-year test.  This is a 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.

B. Second-Year Fellow Experiences

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. 

1. Clinical 

Depending on the career goals of the individual, the clinical appointment is approximately 60-80% 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.  Experience with the Wada procedure is obtained (see below).  Fellows can expect to see approximately 1-2 cases per day, under the technician model.  In addition, fellows often maintain a partial clinical load (e.g., 10%) in the Rehabilitation Laboratory.  

2. Research 

For fellows with a strong research interest, background and career interests, research activity may have an increased emphasis 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.  Typically, this proportion is 20% release time, but may be higher in the second year for fellows with particularly strong interests, aptitude, and productivity in research.  Fellows must obtain approval from their supervisors and the training director/associate director for research release time. 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.  

3. Education

Ongoing educational activities include attendance at Neuroscience Seminar, Benton Lectures, Neuropsychology Rounds, Neurology Grand Rounds, and numerous lectures, colloquia, and seminars offered in the Department of Neurology 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.  

C. Other Special Training Opportunities

1. Wada Testing

As core members of the UI Comprehensive Epilepsy Program, Benton Neuropsychology Clinic neuropsychologists conduct specialized comprehensive “Phase I” evaluations of all candidates for resection surgery for treatment of pharmacoresistant 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, neuropsychologists perform Wada testing on appropriate patients 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. 

2. Stroke Rounds

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 in nature following an acute lesion (for example akinetic mutism or right hemispatial neglect).

3. Neurosurgery 

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 pharmacoresistant epilepsy, beginning with the neuropsychological valuation, through specialized Wada testing, resective surgery, and follow-up.

4. Parkinson’s Disease Multidisciplinary Clinic (MDC)

Neuropsychology is a core member of the MDC for Department of Neurology patients with Parkinson’s Disease with the goal of coordinated and integrated care of “the whole patient” for a wide range of potential problems and issues arising from or impacting on their Parkinson’s disease, adaptive functioning and quality of life. Coordinated by the treating neurologist, the multidisciplinary team includes members from psychiatry, pharmacology, social work, physical therapy and occupational therapy, as well as neuropsychology.  Neuropsychology presents findings and recommendations from our clinical exam to inform the team to address cognitive, behavioral, emotional and psychosocial issues, as well as potential obstacles to the patient and family’s ability to implement the team’s treatment recommendations.