Douglas J. Gelb

Measurement of progression in Alzheimer's disease: a clinician's perspective

Patients with Alzheimers disease (AD) and their families must confront two fundamental truths. First, AD is a uniformly progressive disease that ultimately results in debilitating cognitive impairment. Second, although there is now evidence that some medications may produce transient improvement or possibly even slowing of disease progression, there is currently no way to halt the progression of AD. Consequently, patients and their families consistently ask the following questions: 1. What new management issues can be anticipated, and when? 2. What clinical developments are atypical and merit evaluation for a superimposed problem? 3. Is the current treatment working? These questions can only be answered by referring to the natural course of AD, and specifically, information regarding measures of functional impairment and how they change over time. The information that is currently available on this topic is limited and often embodies implicit assumptions that have not been adequately tested. This information will be reviewed, and directions for future research will be outlined.

Comparison of Healthcare Utilization and Direct Costs in Three Degenerative Dementias

The authors conducted a survey of healthcare utilization in three dementia syndromes to determine whether type of dementia influenced utilization or resulting direct costs. Patients with Alzheimer disease (n=131), dementia with parkinsonism (n=85), and Huntington disease (n=51) were identified from a registry and enrolled. Caregivers completed the mailed survey, and direct costs were estimated. The presence of dementia with parkinsonism resulted in significantly greater utilization of long-term care services and higher total direct costs. In all three groups, long-term care costs accounted for the majority of direct costs. Unique patterns of utilization and costs are seen in specific neurodegenerative dementias.

Alternative calculation of the global clinical dementia rating

SummaryThe Clinical Dementia Rating (CDR) is a widely used instrument for rating the global severity of dementia, with scores in six independently rated categories used as a basis for computing a global score. We have found that the algorithms currently used to calculate the global score from the six component scores produce results that are sometimes inconsistent with the goals of the rating scale. We systematically analyzed these incongruities and developed an alternative algorithm that eliminates them while retaining the fundamental features of the original method.

Education Research: Bias and poor interrater reliability in evaluating the neurology clinical skills examination

Objective: The American Board of Psychiatry and Neurology (ABPN) has recently replaced the traditional, centralized oral examination with the locally administered Neurology Clinical Skills Examination (NEX). The ABPN postulated the experience with the NEX would be similar to the Mini-Clinical Evaluation Exercise, a reliable and valid assessment tool. The reliability and validity of the NEX has not been established. Methods: NEX encounters were videotaped at 4 neurology programs. Local faculty and ABPN examiners graded the encounters using 2 different evaluation forms: an ABPN form and one with a contracted rating scale. Some NEX encounters were purposely failed by residents. Cohen’s kappa and intraclass correlation coefficients (ICC) were calculated for local vs ABPN examiners. Results: Ninety-eight videotaped NEX encounters of 32 residents were evaluated by 20 local faculty evaluators and 18 ABPN examiners. The interrater reliability for a determination of pass vs fail for each encounter was poor (kappa 0.32; 95% confidence interval [CI] = 0.11, 0.53). ICC between local faculty and ABPN examiners for each performance rating on the ABPN NEX form was poor to moderate (ICC range 0.14-0.44), and did not improve with the contracted rating form (ICC range 0.09-0.36). ABPN examiners were more likely than local examiners to fail residents. Conclusions: There is poor interrater reliability between local faculty and American Board of Psychiatry and Neurology examiners. A bias was detected for favorable assessment locally, which is concerning for the validity of the examination. Further study is needed to assess whether training can improve interrater reliability and offset bias.

The impact of MRI on stroke management and outcomes: a systematic review

RATIONALE, AIMS AND OBJECTIVES Magnetic resonance imaging (MRI) is widely used in stroke evaluation and is superior to computed tomography for the detection of acute ischaemia. We sought to evaluate the evidence that conventional MRI influences doctor management or patient outcomes in routine care. METHODS We systematically searched PubMED, EMBASE and proceedings of the International Stroke Conference. Studies were included if they included patients presenting with possible stroke syndromes and they reported MRI results and resulting changes in management or outcome. Multiple reviewers determined inclusion/exclusion for each study, abstracted study characteristics and assessed study quality. RESULTS Of 1813 articles screened, nine studies met inclusion criteria. None were randomized controlled trials, cohort studies or case-control studies. We found little evidence that MRI affects outcomes - one single-centre case series presented three patients. The remaining articles were studies of diagnostic tests or vignette-based studies that described changes in doctor management attributed to MRI. In the studies that suggested MRI influenced management, it did so in two ways. First, MRI distinguished stroke from mimics (e.g. brain tumours), thus enabling more appropriate selection of therapies. Second, even when MRI confirmed a suspected stroke diagnosis, it sometimes provided information (on stroke mechanism, localization, timing or pathophysiology) that influenced management. CONCLUSIONS The impact of MRI on management and outcomes in stroke patients has been inadequately studied. Further research is needed to understand how MRI may productively affect stroke management and outcomes.

Is newer necessarily better? Assessment of a computer tutorial on neuroanatomical localization

Advances in computer technology provide opportunities to present educational material in novel formats, but it is not known whether these approaches are more effective than traditional teaching methods. In an attempt to address this question, I developed a computer tutorial regarding neuroanatomical localization. Localization is often difficult for medical students to learn, and a computer tutorial is an ideal format for teaching students a systematic approach that requires them to remember only a few general principles and a broad outline of the course of a few major fiber tracts. The computer tutorial contained 35 cases, all in the same format: students were presented with two or three symptoms or signs and asked to identify all levels of the CNS for which a unilateral isolated lesion at that level could produce both (or all three) of the symptoms. Students whose answer was incorrect or incomplete were asked to identify the nervous system pathways corresponding to each symptom and the levels where these pathways …

Experience may not be the best teacher Patient logs do not correlate with clerkship performance

Background: With the recent emphasis on core competencies, medical schools and residency programs have attempted to monitor and regulate trainees’ patient encounters. The educational validity of this practice is unknown. Our objective was to determine whether patient encounter logs correlate with educational outcomes. Methods: We reviewed patient logs of all 212 neurology clerkship students from the 2005–2006 academic year and determined the number of patients each student saw in five diagnostic categories (seizure, headache, stroke, acute mental status change, and dementia). We compared these numbers with the students’ written examination scores (total and category-specific) and clinical evaluation scores using Pearson product-moment correlations. Results: The more patients in a given diagnostic category that students saw, the lower the students’ examination subscores in that disease category (r = −0.066, p = 0.03). The total number of patients each student saw did not correlate with the student’s total examination score (r = −0.021, p = 0.77) or the student’s overall clinical performance rating (r = 0.089, p = 0.23). Conclusions: Higher numbers of logged patients did not correlate with better clerkship performance, whether the outcome measures were written tests or faculty ratings, and whether the analysis involved total or disease-specific patient counts. Thus, patient census may not be a meaningful index of educational experience or outcome. Considerable time, money, and effort are required to maintain accurate logs of trainees’ encounters with patients; based on the current study, this may be an inefficient use of resources. IRB = Institutional Review Board; NBME = National Board of Medical Examiners; OSCE = Objective Structured Clinical Examination.

Sex Differences in Academic Rank and Publication Rate at Top-Ranked US Neurology Programs

Importance Women are underrepresented in academic neurology, and the reasons for the underrepresentation are unclear. Objective To explore potential sex differences in top-ranked academic neurology programs by comparing the number of men and women at each academic faculty rank and how many articles each group has published. Design, Setting, and Participants Twenty-nine top-ranked neurology programs were identified by combining the top 20 programs listed on either the 2016 or 2017 Doximity Residency Navigator tool with the top 20 programs listed in the US News and World Report ranking of Best Graduate Schools. An internet search of the departmental websites was performed between December 1, 2015, and April 30, 2016. For each faculty member on a program site, the following biographical information was obtained: first name, last name, academic institution, sex, academic faculty rank, educational leadership (clerkship, fellowship, or residency director/assistant director), and year of medical school graduation. Main Outcomes and Measures To compare the distribution of men vs women and the number of publications for men vs women at each academic faculty rank. Secondary analyses included Scopus h-index, book authorship, educational leadership (clerkship, residency, or fellowship director/assistant director), and clinical activity as inferred through Medicare claims data in men vs women after controlling for years since medical school graduation. Results Of 1712 academic neurologists in our sample, 528 (30.8%) were women and 1184 (69.2%) were men (P < .001). Men outnumbered women at all academic faculty ranks, and the difference increased with advancing rank (instructor/lecturer, 59.4% vs 40.5%; assistant professor, 56.7% vs 43.3%; associate professor, 69.8% vs 30.2%; and professor, 86.2% vs 13.8%). After controlling for clustering and years since medical school graduation, men were twice as likely as women to be full professors (odds ratio [OR], 2.06; 95% CI, 1.40-3.01), whereas men and women had the same odds of being associate professors (OR, 1.04; 95% CI, 0.82-1.32). Men had more publications than women at all academic ranks, but the disparity in publication number decreased with advancing rank (men vs women after adjusting for years since medical school graduation: assistant professor [exponentiated coefficient, 1.85; 95% CI, 1.57-2.12]; associate professor [1.53; 95% CI, 1.22-1.91]; and full professor [1.36; 95% CI, 1.09-1.69]). Men had a higher log Scopus h-index than women after adjustment (linear coefficient, 0.44; 95% CI, 0.34-0.55). There was no significant association between sex and clinical activity (linear coefficient, 0.02; 95% CI, −0.10 to 0.13), educational leadership (OR, 1.09; 95% CI, 0.85-1.40), or book authorship (OR, 2.75; 95% CI, 0.82-9.29) after adjusting for years since medical school graduation. Conclusions and Relevance Men outnumber women at all faculty ranks in top-ranked academic neurology programs, and the discrepancy increases with advancing rank. Men have more publications than women at all ranks, but the gap narrows with advancing rank. Other measures of academic productivity do not appear to differ between men and women.

Where's the logic in neurologic education?

Current practices in neurologic education, and medical education in general, are based largely on intuition and tradition rather than empiric evidence. Educational practices can and should be rigorously evaluated. The topics to be investigated fall into one or more of three broad categories: What should we teach? How should we teach it? How do we know what they have learned? This paper presents examples of research in each of these categories.

Advice for clinician educators

Not long ago, the idea of making education the focus of an academic career in neurology would have been heretical. Many of us were taught that to be an academic neurologist, anything less than a triple threat—a master clinician, teacher, and researcher—was unacceptable. For a variety of reasons, the triple threat is no longer maintained as a universal ideal, and academic neurologists whose focus is education (typically referred to as clinician–educators) have gained respectability. This career path remains a little out of the mainstream, however, and it is less standardized than the traditional academic path focusing on research. Educational productivity is harder to measure than research and clinical productivity. The metrics by which research is judged—publications, citations, and external support— do not apply to teaching. Unlike clinical activity and research activity, teaching activity is divorced from a direct revenue stream in most academic medical centers. Different medical centers and different departments have approached these issues in various ways, so it is difficult to offer specific career advice that would be pertinent in all settings, but some broad principles apply. In this article, I offer some general advice and observations for neurologists hoping to develop a career focusing on education.