Expert Guest Session: Clinical Neuropsychology with Dr. Jacqueline Becker

Speaker Introduction and Professional Affiliation

• Speaker: Dr. Jacqueline Becker, Clinical Neuropsychologist.

• Current Role: Assistant Professor at the Icahn School of Medicine at Mount Sinai in New York City.

• Departmental Placement: Uniquely housed within the Department of Medicine, Division of General Internal Medicine.

  • Dr. Becker is largely surrounded by Medical Doctors (MDs) and is one of the very few PhDs in the department—and the only one in her specific division.

Defining Neuropsychology and the Clinical Role

• The "Translator" Metaphor: Dr. Becker describes herself as a translator who takes invisible cognitive processes and converts them into measurable data.

  • Invisible Processes: Attention, memory, processing speed, and language.

  • Patient Experience: Patients often report feeling "less sharp," being unable to multitask as they once did, or struggling with changes in their daily functional routine without knowing why.

• Formal Definition: Neuropsychology is the study of brain-behavior relationships.

  • It examines how injury, illness, or disease changes the way individuals think, feel, and function.

• Neuropsychology vs. Neuroimaging (MRI/CT):

  • Neuroimaging: Focuses on brain structure. This can sometimes yield false negatives (a struggling patient with a normal MRI) or incidental findings (a brain tumor or cyst in a patient who feels fine).

  • Neuropsychology: Focuses on brain function. It provides measurable data that translates directly to a patient’s experience in daily life.

The Neuropsychological Evaluation Process

• Objective Assessment: The evaluations use standardized, precise tests that are considered objective rather than reliant solely on clinical judgment.

• Standardization and Normative Data:

  • Every patient takes the same set of tests to ensure fairness.

  • Comparison Method 1 (Population Norms): Scores are compared to the general population based on age, education level, and sex.

  • Comparison Method 2 (Self-Baseline): Scores are compared to that specific individual’s expected performance based on their baseline Intelligence Quotient ($IQ$).

• Workflow of an Evaluation:

  1. Intake Interview: A face-to-face meeting (typically $1$ to $1.5\,\text{hours}$) with the patient, and often a spouse, caregiver, or parent (for pediatric cases) to obtain a comprehensive history.

  2. Standardized Testing: A series of tests administered to measure specific cognitive functions.

  3. Scoring and Reporting: Data is scored and synthesized into a comprehensive written report.

  4. Diagnosis: Disentangling cognitive changes to determine if they are caused by disease, injury, poor sleep, low mood, or medication side effects.

Treatment and Accommodations

• Cognitive Rehabilitation (Cog Rehab):

  • Theory: Based on neuroplasticity—the concept that "neurons that fire together wire together."

  • Application: Strengthening neural networks through repetitive practice.

  • Efficacy: Research is mixed. It works effectively for stroke recovery but has not been shown to reverse cognitive decline associated with normal aging.

• Patient Roadmaps: Reports provide guidance on which treatments will work and suggest accommodations.

  • Education: Extended time on tests or specific school-based support.

  • Workplace: Reduced work weeks or remote work options.

Research and Professional Paths

• Investigator Track: Dr. Becker is currently on a track where $100\%$ of her time is dedicated to research, funded by grants.

• Circular Feedback Loop: Clinical work informs research questions, and research findings directly improve patient care.

• Common Work Settings:

  • Academic Medical Centers and Hospitals.

  • Rehabilitation settings and Veteran Affairs ($VA$) hospitals.

  • Forensic settings (court-ordered evaluations or disability assessments).

  • Private Practice.

  • Pharmaceutical, Neurotech, or Biotech consulting: Assisting companies in understanding the "clinical meaningfulness" of new drugs (e.g., Alzheimer’s treatments) beyond what blood tests or scans show.

Cognitive Domains and Brain Connectivity

• Cognition as a Network: The brain should not be viewed as a single entity but as a series of domains working in coordination.

• Key Domains:

  • Attention: The foundation; information must be attended to before it can be stored.

  • Memory: The ability to take in, hold, and recall information.

  • Language: Necessary for processing verbal information (e.g., word lists).

  • Visual-Spatial Abilities: Necessary for processing visual information.

  • Executive Functioning: Often called the "CEO of the brain." This includes planning, organizing, self-control, emotional regulation, and cognitive flexibility.

Educational and Training Requirements

• Undergraduate: Bachelor’s degree (typically in Psychology, Sociology, Biology, or Neuroscience).

• Master's Degree (Optional): Dr. Becker obtained a $2\text{-year}$ Master’s in Mental Health Counseling and worked as a therapist before her PhD.

• Doctorate ($PhD$ or $PsyD$):

  • PhD (Doctor of Philosophy): Focuses on both research and clinical work ($50/50$ split). Usually funded (tuition paid plus a small stipend).

  • PsyD (Doctor of Psychology): More clinical focus with less research. Typically not funded (students pay tuition).

  • Duration: Generally $5$ to $7\,\text{years}$.

• Doctoral Internship: A $1\text{-year}$ full-time clinical requirement (equivalent to residency). Dr. Becker completed hers at Harvard Medical School/Massachusetts General Hospital.

• Postdoctoral Fellowship: A $2\text{-year}$ specialized training period required to use the title "Neuropsychologist." Dr. Becker completed hers at Northwell Health.

• Licensure: Passing a state-level examination after fellowship.

• Board Certification: Considered the "gold standard" for clinical work, though not always required for research tracks.

• Competitive Nature: Fordham University’s PhD program received over $2,000$ applications for only $7$ available spots in a recent cycle.

Significant Clinical and Research Experiences

• Awake Craniotomies: Dr. Becker has participated in "awake brain surgery" to perform language mapping. While the surgeon operates, the neuropsychologist engages the twilighted patient in conversation and testing to ensure the preservation of eloquent cortex.

• Sports Neuropsychology: Worked with the New York Jets and New York Islanders to establish baseline cognitive scores pre-season to monitor the impact of concussions and chronic traumatic encephalopathy ($CTE$).

• Chronic Illness Research: Studied cognitive impacts of asthma, $COPD$, breast cancer, diabetes, and liver transplants.

• Long COVID Research: In April $2020$, Dr. Becker helped establish the Mount Sinai post-COVID registry. Her team was among the first to document "Long COVID" and its cognitive "brain fog," validating patient symptoms that were previously dismissed as subjective or anxiety-based.

Daily Life and Practice Realities

• Flexibility: Research-heavy roles allow for remote work ($3$ to $4\,\text{days/week}$) and self-scheduled patient visits ($1$ to $2\,\text{days/week}$).

• Soft Money: In research roles, the neuropsychologist must often secure grants to support their own salary.

• Psychometrists: Many clinical practices use psychometrists—technicians with Bachelor’s degrees trained specifically to administer and score tests—while the neuropsychologist focuses on selection and interpretation.

• High Demand: Patient waitlists for neuropsychological evaluations, even at large centers like Sinai, can exceed $1\,\text{year}$.

Questions & Discussion

• Treatment for Cognitive Decline: There are currently no genetic therapies or treatments that reverse cognitive decline; some Alzheimer's drugs may slow progression if captured early.

• Social Cognition: "Social aptitude" falls under the domain of Social Cognition, involving "theory of mind," which is often impaired in conditions like autism.

• Head Injuries: A remote history of a mild head injury is unlikely to cause severe symptoms years later, but severe injuries involving coma/loss of consciousness can leave lasting deficits. Repeated blows (like in football) can lead to protein aggregations (tau and $TDP\text{-}43$) associated with $CTE$.

• Diagnosis and Mental Health: Neuropsychologists can diagnose Mental Health conditions like $ADHD$ and Autism, as well as neurologic conditions using codes from the $ICD\text{-}10$.

• Advice for PhD Applicants: Research experience is mandatory (posters, co-authoring). Grades matter, but a cohesive "story" of professional trajectory and personality fit are equally vital.

• Networking: Professional organizations like the American Psychological Association ($APA$), National Academy of Neuropsychology ($NAN$), and International Neuropsychological Society ($INS$) are essential for career growth.

• Writing and AI: Genuine writing skills are critical. Dr. Becker noted that AI-generated drafts are usually very obvious to experienced reviewers and can be professionally embarrassing for the applicant.