Ralph Jozefowicz

The neurology clerkship core curriculum

Abstract—Neurologic symptoms are common in all practice settings, and neurologic diseases comprise a large and increasing proportion of health care expenditures and global disease burden. Consequently, the training of all physicians should prepare them to recognize patients who may have neurologic disease, and to take the initial steps in evaluating and managing those patients. We present a core curriculum outlining the clinical neurology skills and knowledge necessary to achieve that degree of preparation. The curriculum emphasizes general principles and a systematic approach to patients with neurologic symptoms and signs. The ability to perform and interpret the neurologic examination is fundamental to that approach, so the curriculum delineates the essential components of the examination in three different clinical settings. The focus of the curriculum is on symptom-based rather than disease-based learning. The only specific diseases selected for inclusion are conditions that are common or require urgent management. This curriculum has been approved by the national organization of neurology clerkship directors and endorsed by the major national professional organizations of neurologists. It is intended as a template for planning a neurology clerkship and as a benchmark for evaluating existing clerkships. It should be especially helpful to clerkship directors, neurology chairs, deans of medical education, and members of external accreditation groups.

how Much Neurology Should a Medical Student Learn? A Position Statement of the Aan Undergraduate Education Subcommittee

Neurologic disease, already common in the United States, will become even more common in the future. But presently, neurology education at the undergraduate level and in primary care residencies is declining and does not adequately train physicians to manage neurologic illness. The authors maintain that this serious problem can be partially addressed by improving the neurology education of all primary care physicians and by allowing students access to neurology specialists. The education of medical students in the basic and clinical neurosciences must be integrated into a seamless curriculum over the four years of medical education. This education experience must be taught through a team approach and must be led by both a clinician and a basic scientist. All medical students must acquire the knowledge, skills, and attitudes necessary to perform an initial evaluation of the patient with a neurologic complaint. Finally, students must understand the role and recognize the importance of the neurologist and know when consultation is needed. This continuum of neurology education must be financially supported by the institution, and course leaders who show excellence in education must be rewarded with compensation and promotion.

Education Research: Neurology training reassessed The 2011 American Academy of Neurology Resident Survey results

Objective: To assess the strengths and weaknesses of neurology resident education using survey methodology. Methods: A 27-question survey was sent to all neurology residents completing residency training in the United States in 2011. Results: Of eligible respondents, 49.8% of residents returned the survey. Most residents believed previously instituted duty hour restrictions had a positive impact on resident quality of life without impacting patient care. Most residents rated their faculty and clinical didactics favorably. However, many residents reported suboptimal preparation in basic neuroscience and practice management issues. Most residents (71%) noted that the Residency In-service Training Examination (RITE) assisted in self-study. A minority of residents (14%) reported that the RITE scores were used for reasons other than self-study. The vast majority (86%) of residents will enter fellowship training following residency and were satisfied with the fellowship offers they received. Conclusions: Graduating residents had largely favorable neurology training experiences. Several common deficiencies include education in basic neuroscience and clinical practice management. Importantly, prior changes to duty hours did not negatively affect the resident perception of neurology residency training.

Trends in American Board of Psychiatry and Neurology specialties and neurologic subspecialties

Objective: To review the current status and recent trends in the American Board of Psychiatry and Neurology (ABPN) specialties and neurologic subspecialties and discuss the implications of those trends for subspecialty viability. Methods: Data on numbers of residency and fellowship programs and graduates and ABPN certification candidates and diplomates were drawn from several sources, including ABPN records, Web sites of the Accreditation Council for Graduate Medical Education and the American Medical Association, and the annual medical education issues of the Journal of the American Medical Association. Results: About four-fifths of neurology graduates pursue fellowship training. While most recent neurology and child neurology graduates attempt to become certified by the ABPN, many clinical neurophysiologists elect not to do so. There appears to have been little interest in establishing fellowships in neurodevelopmental disabilities. The pass rate for fellowship graduates is equivalent to that for the “grandfathers” in clinical neurophysiology. Lower percentages of clinical neurophysiologists than specialists participate in maintenance of certification, and maintenance of certification pass rates are high. Conclusion: The initial enthusiastic interest in training and certification in some of the ABPN neurologic subspecialties appears to have slowed, and the long-term viability of those subspecialties will depend upon the answers to a number of complicated social, economic, and political questions in the new health care era.

Neurologic Complications of Respiratory Disease

The respiratory and central nervous systems are intimately connected through strict control of ventilation by central mechanisms. The exquisite sensitivity of central chemoreceptors and cerebral blood vessels to changes in central nervous system oxygenation mandate this type of control to maintain proper brain function. When diseases of the lung and respiratory system interfere with this fine balance, neurologic symptoms, sometimes severe, may develop. This article deals with the effects of abnormal ventilation on the nervous system.

Advances in neurological education : A time to share

Neurological education in medical schools and residency programs has changed dramatically over the past decade. New mandates from regulatory agencies, such as the Liaison Committee for Medial Education (LCME), Accreditation Council for Graduate Medical Education (ACGME), and American Board of Medical Specialties (ABMS), have had a profound effect on curriculum and evaluation of medical students and residents. In addition, major initiatives in neurological education by the American Academy of Neurology (AAN), the American Neurological Association (ANA), and the Association of University Professor of Neurology (AUPN) have also had an impact on Neurology curricula in medical schools and residency programs, with one goal being the recruitment and retention of high-quality US medical students in Neurology residency training programs. One of the responses of the medical profession to concerns over the delivery of health care has been to tighten the requirements for medical student education, residency education, and physician education. The Accreditation Council for Graduate Medical Education has established six core competencies (medical knowledge, patient care, professionalism, interpersonal and communication skills, practice-based learning and improvement, and systems-based practice) that all residents must master to complete residency training. In addition, the Residency Review Committees will be focusing on outcomes rather than process when evaluating residency training programs. The Residency Review Committees have previously evaluated whether residency programs have the potential to educate residents in a specialty by focusing on curriculum, number of faculty, number of patients, variety of conferences, and so forth. In the future, they will focus on whether residency programs are actually teaching the residents, by evaluating performance of these residents in practice. Concerns for patient safety have resulted in limits on work hours for residents. Lastly, medical schools and residency programs are placing new emphasis on evidence-based medicine and cost-effective health care as possible solutions to the tensions resulting from rising medical costs, advancing technology, and the need to improve medical education. The following three sections consider advances in neurological education for medical students, restructuring residency training in Neurology, and teaching Neurology residents how to enter the workforce.

The challenges of residents teaching neurology.

Background:Teaching is integrated into the daily practice of residents, and it is a skill necessary for practice as well as academics. The settings in which teaching and learning take place are ubiquitous but include classrooms, small groups, bedside rounds, and grand rounds. Given the learning environment of residency, neurology residents should have working knowledge of basic principles of effective teaching to make learning successful. Teaching also reinforces knowledge, and residents will likely be better practitioners if some basic skills of teaching are practiced. Review Summary:Neurology teaching techniques for residents are rarely addressed in the medical literature. Although information regarding teaching principles in medicine exists, there is little information regarding how residents teach. We examine and review some of the more effective methods and appreciated qualities in teachers, with a particular emphasis for the neurology resident. We also review whom neurologists need to teach and the various settings in which teaching may take place. Conclusions:Neurology residents encounter a variety of audiences in a variety of settings that require diverse teaching skills to effectively convey information to other providers as well as patients. The majority of these skills should be learned in residency to establish a foundation for teaching, regardless of future practice settings.

Neurology Education: Current and Emerging Concepts in Residency and Fellowship Training

This article discusses the current and future state of neurology training. A priority is to attract sufficient numbers of qualified candidates for the existing residency programs. A majority of neurology residents elects additional training in a neurologic subspecialty, and programs will have to be accredited accordingly. Attempts are being made to standardize and strengthen the existing general residency and subspecialty programs through cooperative efforts. Ultimately, residency programs must comply with the increasing requirements and try to adapt these requirements to the unique demands and realities of neurology training. An effort is underway to establish consistent competency-testing methods.

Education Research: Positive effect of scheduled faculty modeling on clerkship student bedside skills exposure and learning

Objective: To evaluate the effect of scheduled bedside skills modeling for third-year medical students on their neurology clerkship. Methods: During the 2012–2014 academic years, 56 third-year medical students participated in a curricular pilot program involving a scheduled bedside skills modeling experience during the first week of their neurology clerkship, whereas 131 students underwent the typical rotation. The experience consisted of observing a faculty member conduct a comprehensive encounter on a new outpatient. To promote active learning, students were provided an observation guide to document questions and observations. An anonymous survey was conducted at the end of each clerkship block assessing student exposure to bedside skills modeling. Using qualitative thematic analysis, observation guide statements were transcribed and coded into emergent learning themes. Results: A total of 57.4% (95% confidence interval [CI] 43.3%–71.5%) of students in the modeling group reported observing both a comprehensive history and neurologic examination vs 37.5% (95% CI 28.2%–46.8%) in the nonmodeling groups (p = 0.023). A total of 253 observation statements were transcribed and coded from the observation guides. The most common learning themes included (1) strategies for performing a neurologic examination, (2) techniques for eliciting a neurologic history, and (3) importance of detail and thoroughness of the history and examination. Conclusions: Our study demonstrated that there was a significant increase in structured observation by students of neurologic bedside skills with the inclusion of a scheduled modeling experience, and we provide a qualitative description of the most common learning themes associated with this experience.

Formal faculty observation and assessment of bedside skills for 3rd-year neurology clerks

Objective: To evaluate the feasibility and utility of instituting a formalized bedside skills evaluation (BSE) for 3rd-year medical students on the neurology clerkship. Methods: A neurologic BSE was developed for 3rd-year neurology clerks at the University of Rochester for the 2012–2014 academic years. Faculty directly observed 189 students completing a full history and neurologic examination on real inpatients. Mock grades were calculated utilizing the BSE in the final grade, and number of students with a grade difference was determined when compared to true grade. Correlation was explored between the BSE and clinical scores, National Board of Medical Examiners (NBME) scores, case complexity, and true final grades. A survey was administered to students to assess their clinical skills exposure and the usefulness of the BSE. Results: Faculty completed and submitted a BSE form for 88.3% of students. There was a mock final grade change for 13.2% of students. Correlation coefficients between BSE score and clinical score/NBME score were 0.36 and 0.35, respectively. A statistically significant effect of BSE was found on final clerkship grade (F2,186 = 31.9, p < 0.0001). There was no statistical difference between BSE score and differing case complexities. Conclusions: Incorporating a formal faculty-observed BSE into the 3rd year neurology clerkship was feasible. Low correlation between BSE score and other evaluations indicated a unique measurement to contribute to student grade. Using real patients with differing case complexity did not alter the grade.