Dara V. Albert

Structure of neuroscience clerkships in medical schools and matching in neuromedicine.

Objective: Due to the burden of neurologic disease, there is high demand for neurologists, child neurologists, and neurosurgeons. Only 2.6% of graduating medical students matched in neuromedicine residencies in 2014. This number will not likely meet the needs of the population or the projected shortfall. To compensate for this, the medical education system has an obligation to ensure competence in neuromedicine for all trainees and mentorship for students pursuing training in the field. We aim to evaluate the state of the neurology clerkship in US medical schools and how this impacts graduates entering the field. Methods: Publicly available curricula of 158 US medical schools were reviewed. Presence of a required neurology clerkship, its duration, and the year offered were tabulated, as were the availability of child neurology and neurosurgery electives and affiliated neuromedicine residencies. The total graduating students from each medical school matching into neuromedicine residencies for 2011–2014 were recorded. Repeated-measure analysis of variance was used to assess the relationship of these variables to number of students matching into the collective neuromedicine. Results: All but 4 schools (97%) published clerkship information. Neurology was a required clerkship at 56% of reporting institutions. Residency match data were not published from 53 schools (35%) and these were excluded from the analysis. In the remaining schools, all variables showed a relationship to students matching in neuromedicine residencies. Conclusions: The presence of a required neurology clerkship and opportunities for students to explore neuromedicine during medical school correlates with students matching into neuromedicine residencies.

Education Research: Case logs in the assessment of medical students in the neurology outpatient clinic

Objective: Using outpatient neurology clinic case logs completed by medical students on neurology clerkships, we examined the impact of outpatient clinical encounter volume per student on outcomes of knowledge assessed by the National Board of Medical Examiners (NBME) Clinical Neurology Subject Examination and clinical skills assessed by the Objective Structured Clinical Examination (OSCE). Methods: Data from 394 medical students from July 2008 to June 2012, representing 9,791 patient encounters, were analyzed retrospectively. Pearson correlations were calculated examining the relationship between numbers of cases logged per student and performance on the NBME examination. Similarly, correlations between cases logged and performance on the OSCE, as well as on components of the OSCE (history, physical examination, clinical formulation), were evaluated. Results: There was a correlation between the total number of cases logged per student and NBME examination scores (r = 0.142; p = 0.005) and OSCE scores (r = 0.136; p = 0.007). Total number of cases correlated with the clinical formulation component of the OSCE (r = 0.172; p = 0.001) but not the performance on history or physical examination components. Conclusion: The volume of cases logged by individual students in the outpatient clinic correlates with performance on measures of knowledge and clinical skill. In measurement of clinical skill, seeing a greater volume of patients in the outpatient clinic is related to improved clinical formulation on the OSCE. These findings may affect methods employed in assessment of medical students, residents, and fellows.

Why neurology? Factors which influence career choice in neurology.

Objective: To evaluate the factors which influence the decision to pursue a career in neurology. Methods: An anonymous survey was developed using a Likert scale to rate responses. The survey was sent to adult and child neurology faculty, residents and fellows, as well as medical students applying for neurology. Descriptive statistics were used to analyse the factors of influence. Respondents were subsequently categorized into pre-neurology trainees, neurology trainees, child neurologists and adult neurologists, and differences between the groups were analysed using Pearson’s chi-square test. Results: One hundred and thirty-three anonymous responses were received. The respondents were neurologists across all levels of training and practice. Across all respondents, the most common factor of high importance was intellectual content of specialty, challenging diagnostic problems, type of patient encountered and interest in helping people. Responses were similar across the groups; however, the earliest trainees cited interest in helping people as most important, while those in neurology training and beyond cite intellectual content of the specialty as most important. Discussion: As trainees transition from their earliest levels of clinical experience into working as residents and faculty, there is a shift in the cited important factors. Lifestyle and financial factors seem to be the least motivating across all groups. Encouragement from peers, mentors, faculty and practicing physicians is considered high influences in a smaller number of neurologists. This may present an opportunity for practicing neurologists to make connections with medical students early in their education in an effort to encourage and mentor candidates.

Comparison of semiologies between tilt-induced psychogenic nonsyncopal collapse and psychogenic nonepileptic seizures☆

We sought to characterize the clinical features of tilt-induced psychogenic nonsyncopal collapse (PNSC) from a cohort of young patients and to compare the semiologies between PNSC and EEG-confirmed psychogenic nonepileptic seizures (PNES). A PNSC diagnosis was made if a clinical event occurred during tilt-table testing that the patient regarded as fainting, but neither hypotension nor EEG changes were present. A diagnosis of PNSC was made in 17.6% of all patients referred during the 15-month study period. Cohorts with psychogenic nonsyncopal collapse (n=40) and PNES (n=40) did not differ in age (15.5±2.2 versus 14.6±2.7, p=.11) or female gender (80% versus 72.5%, p=.43). Psychogenic nonsyncopal collapse events were briefer than PNES events (median: 45 versus 201.5s, p<.001). Negative motor signs (head drop, body limpness) predominated in PNSC (85% versus 20%, p<.001), while the positive motor signs of convulsion occurred more often with PNES (90% versus 30%, p<.001). Behavioral arrest (25% versus 32.5%, p=.46) and eye closure (85% versus 72.5%, p=.21) did not differ between PNSC and PNES. Patients with PNSC were more likely to be tearful before (30% versus 7.5%, p=.02) and after (62.5% versus 7.5%, p<.001) an event. In conclusion, although overlap exists, the features of PNSC generally appear similar to neurally mediated syncope, while the features of PNES generally appear similar to epileptic seizures. Psychogenic nonsyncopal collapse and PNES likely represent similar disorders that differ primarily by clinical semiologies and referral patterns.

Unique Characteristics of the Photoparoxysmal Response in Patients With Neuronal Ceroid Lipofuscinosis Type 2 Can EEG Be a Biomarker

Objective: The objective was to identify unique features of the photoparoxysmal response seen in patients with neuronal ceroid lipofuscinosis type 2 as compared to patients with a photoparoxysmal response associated with other epilepsy syndromes. Methods: Electroencephalograms from patients with neuronal ceroid lipofuscinosis type 2 seen at the authors’ institution in the past 10 years as well as electroencephalograms (EEGs) reported to have a photoparoxysmal response during a single year were reviewed. Results: A photoparoxysmal response was seen in 60% of the patients with neuronal ceroid lipofuscinosis type 2. This was most commonly seen with low frequency intermittent photic stimulation (76%) which often occurred in a time-locked fashion (63%) and was seen on the patient’s initial EEG (78%). A unique pattern the authors called “sentinel” discharge was identified in 30% of EEGs in patients with neuronal ceroid lipofuscinosis. Conclusions: Photoparoxysmal responses in patients with neuronal ceroid lipofuscinosis type 2 have features which are distinguishing from photoparoxysmal responses seen in other epilepsies.

Views on Careers in Clinical Neurosciences Among Neurosurgeons and Neurologists in China

BACKGROUND China has a large and aging population. The need for physicians with training in clinical neurosciences will grow. There is little known regarding the factors that lead physicians in China to pursue careers in clinical neurosciences. The objective of this study was to garner a clearer understanding of factors that influence physicians to pursue careers in neurosurgery and neurology in China. METHODS We surveyed attendees at a national neuroscience conference on the factors that influence their pursuit of careers in clinical neurosciences. Responses were quantified on a Likert scale. One-way analysis of variance was used to compare different groups of respondents. RESULTS Factors associated with the intellectual elements of the specialties were rated most highly. Differences were noted between respondents, with trainees rating lifestyle-related factors more highly compared with attending physicians. CONCLUSIONS The intellectual challenges are important factors for physicians in China influencing the pursuit of careers in the clinical neurosciences. This finding echoes results found elsewhere in the world. However, differences with trainees elsewhere in the world emerge when evaluating additional factors influencing trainees pursuing careers in the clinical neurosciences. Trainees in China rate educational experiences and mentorship more highly, whereas U.S. trainees rate altruistic goals more highly. This study provides a clearer understanding of factors influencing career choice among clinical neuroscientists in China.

Ambulatory training in neurology education

Much of the care provided by practicing neurologists takes place in outpatient clinics. However, neurology trainees often have limited exposure to this setting. Adequate incorporation of outpatient care in neurology training is vital; however it is often hampered by numerous challenges. We detail a number of these challenges and suggest potential means for improvement.

Child Neurology Education for Pediatric Residents:: How Are We Doing?

The aim of this study was to evaluate whether the current state of child neurology education during pediatric residency provides adequate preparation for pediatric practice. A survey was sent to recent graduates from 3 pediatric residency programs to assess graduate experience, perceived level of competence, and desire for further education in child neurology. Responses from generalists versus subspecialists were compared. The response rate was 32%, half in general pediatric practice. Only 22% feel very confident in approaching patients with neurologic problems. This may represent the best-case scenario as graduates from these programs had required neurology experiences, whereas review of Accreditation Council of Graduate Medical Education–accredited residency curricula revealed that the majority of residencies do not. Pediatric neurologic problems are common, and pediatric residency graduates do encounter such problems in practice. The majority of pediatricians report some degree of confidence; however, some clear areas for improvement are apparent.

Breadth versus volume: Neurology outpatient clinic cases in medical education

This study examined how volume in certain patient case types and breadth across patient case types in the outpatient clinic setting are related to Neurology Clerkship student performance. Case logs from the outpatient clinic experience of 486 students from The University of Chicago Pritzker School of Medicine, USA, participating in the 4week Neurology Clerkship from July 2008 to June 2013 were reviewed. A total of 12,381 patient encounters were logged and then classified into 13 diagnostic categories. How volume of cases within categories and the breadth of cases across categories relate to the National Board of Medical Examiners Clinical Subject Examination for Neurology and a Neurology Clerkship Objective Structured Clinical Examination was analyzed. Volume of cases was significantly correlated with the National Board of Medical Examiners Clinical Subject Examination for Neurology (r=.290, p<.001), the Objective Structured Clinical Examination physical examination (r=.236, p=.011), and the Objective Structured Clinical Examination patient note (r=.238, p=.010). Breadth of cases was significantly correlated with the National Board of Medical Examiners Clinical Subject Examination for Neurology (r=.231, p=.017), however was not significantly correlated with any component of the Objective Structured Clinical Examination. Volume of cases correlated with higher performance on measures of specialty knowledge and clinical skill. Fewer relationships emerged correlating breadth of cases and performance on the same measures. This study provides guidance to educators who must decide how much emphasis to place on volume versus breadth of cases in outpatient clinic learning experiences.

Diagnosis of ESES with 100 seconds of sleep.

Purpose: Strategies for diagnosing electrical status epilepticus during slow-wave sleep (ESES) vary among interpreting neurologists. Our aim was to evaluate if the spike-wave index (SWI) for the first 100 seconds of sleep is reflective of the SWI when compared with a conventional method. Methods: We reviewed EEGs from 2005 to 2011 that were considered diagnostic of ESES based on unspecified methods. The SWI for the first nonrapid eye movement sleep cycle (long method) was calculated by two neurophysiologists. Two different neurophysiologists calculated SWI for the first 100 seconds of sleep (short method). For the purposes of this study, ESES was defined as an SWI of >85%. The two SWI scores were compared. Results: Fourteen EEGs were reviewed. Despite being considered by the initial interpreter as diagnostic of ESES, only 4 of the studies had an SWI of >85% based on each of the methods. For a diagnosis of ESES, the sensitivity of the short method is 80% and the specificity is 89%. Wilcoxon signed rank test was used to compare the long and short methods. A P value of 0.70 indicates no significant difference between the methods. Additionally, the Spearman correlation coefficient is 0.553 (P = 0.04), indicating moderate correlation between the methods. Conclusions: The SWI for the first 100 seconds of nonrapid eye movement sleep is predictive of the SWI for the entire first sleep cycle with a good sensitivity and specificity in our cohort. This suggests an alternative method for diagnosing ESES, which is comparable to analysis of a full night of sleep.