Thomas H. Glick

Evidence-guided education: patients' outcome data should influence our teaching priorities.

How should medical educators choose learning objectives and teaching content in clinical education? Given the information chain reaction, coverage of all significant topics in sufficient depth is not possible. Choosing subjects of high priority is essential if education is to have maximum impact on quality of care. These priorities should not derive from tradition and opinion, but should be informed by patient outcomes, the ultimate standard for assessing educational effectiveness. Building upon prior initiatives linking education to practice, the author uses the term “evidence-guided education” to express the process of influencing curricular choices with evidence from health outcomes. Sources of outcome evidence include incident reports, morbidity and mortality conferences, surveillance of quality of care in particular venues, case series, surveys of adverse events and “near-misses,” and malpractice claims. Starting with anecdotal occurrences, additional case-finding may establish patterns of poor outcomes, some of which may be preventable. Credible research data on outcomes can inform prioritization for objectives and content at successive institutional levels, which should improve practices and outcomes, completing the loop of feedback, implementation, and improved health. The closer the educational intervention is to practice, the more accountable it becomes. Thus, EGE is more amenable to evaluation at residents’ and practitioners’ levels and more difficult at the undergraduate level. However, outcome evidence should still inform undergraduate teaching, since this constitutes the platform for future learning. Severe constraints on learning time mandate prioritization of content and suggest the need for the judicious application of outcome evidence in place of mere opinion.

Crafting cases for problem‐based learning: experience in a neuroscience course

Clinical cases for problem‐based learning should capture the relevance of patient encounters, and not serve merely as a ‘take‐off’ point for scientific study. As a vehicle of learning, the case should drive the science and the science should drive the case. Decision points elicit intellectual commitment, and help to raise the level of inquiry. Our cases are focused, avoiding clinical complexity and reliance on pattern recognition. We emphasize formulation of evidence‐based mechanistic hypotheses. The case does not stand alone, but must suit its position in the course and curriculum.

Time to learn: the outlook for renewal of patient‐centred education in the digital age

Major forces in society and within health systems are fragmenting patient care and clinical learning. The distancing of physician and trainee from the patient undermines learning about the patient‐doctor relationship. The disconnection of care and learning from one successive venue to another impedes the ability of trainees to learn about illness longitudinally.

How best to evaluate clinician-educators and teachers for promotion?

The challenge of how best to evaluate educational scholars (and specifically, clinician—educators) and teachers for promotion continues to confront academia. While the work of educational scholars and teachers often overlaps, the terms for justifying their promotion differ substantially. In each case, the author maintains that evaluation should be oriented to evidence of the impact of their work. Educational scholars can be assessed mainly by objective impact, whereas the evidence for the impact of teachers should include profound, subjective effects on individual learners. For example, for clinician—educators engaged in scholarly work, the impact of that work can be identified in terms of changes in educational methods, career commitments, and practices (all intermediate outcomes), and even health outcomes. For teachers, in addition to customary criteria such as critical thinking, depth of knowledge, communication ability, and personal engagement, learners can be asked about the deep influence of these teachers. The author states his case for these principles, and also presents an innovative tool, the “impact map,” as a way of graphically portraying the track record of an individual clinician—educator. Such maps are more vivid than narrative testimonials in organizing and displaying evidence of impact over time. This tool, combined with the authors other suggestions to assist the promotion process for educators and teachers, is aimed at fostering a greater emphasis on outcomes in assessing both clinician—educators and teachers to achieve greater rigor and fairness.

Neurologic patient safety: An in-depth study of malpractice claims

This in-depth study of neurologic malpractice claims indicated authentic, preventable patient harm in 24 of 42 cases, enabling comparison with larger but administratively abstracted summary reports. Principal findings included the common occurrence of outpatient events, lapses in communication with patients and other providers, the need for follow-through by the consultant neurologist even when not primarily responsible, the frequency of diagnostic errors, and pitfalls associated with imaging.

Malpractice claims: Outcome evidence to guide neurologic education?

Article abstract— The choice of objectives and content in neurologic education should be informed by evidence from patient outcomes and errors. Malpractice claims are proposed as one data source, although they only partially reflect health outcomes. Epidemiologic, statewide data suggest some provisional priorities for key topics and training targets, but require further research to assess their value for guiding neurologic education.

The neurologist and patient safety.

Background:The objective of this article is to acquaint neurologists with the current status of evidence and opinion on patient safety in neurology. Research data on errors and preventable adverse events (harm from medical management) in neurology are sparse, with little light being cast thus far on the vulnerabilities of individual neurologists and neurologic office practices. However, areas of particular concern and lines of appropriate action are now becoming apparent. Review Summary:This review draws on the few studies of neurologic malpractice claims, inpatient incident reports and chart reviews, and articles and abstracts in the journal literature. These are placed in the context of the general epidemiology of medical errors, adverse events, and approaches to remediation. Conclusion:Accurate and timely diagnosis in all its aspects represents the single largest category of error. Most neurologists have their first interaction with a patient and family at the time of a critical illness, underlining the importance of improved communication, not only with them but with other caregivers. Systems of information transfer, such as those enabling timely imaging reports, are critical. Better consultative follow-up may be pivotal. Education in patient safety competencies and closer supervision of trainees can be expected to improve protection. Venues, such as emergency departments, in which relevant knowledge and skills may be insufficient to maximize patient safety, deserve particular attention.

Neurologists for patient safety : Where we stand, time to deliver

Neurologists have a professional opportunity, an ethical responsibility, and sound clinical and economic reasons for engaging in efforts to improve patient safety. Better communication with patients and other providers, closer follow-up of consultation cases, and more focused supervision of trainees will help to reduce current patterns of error and misunderstanding. Patient education with attention to health literacy should improve adherence to management plans and help to bridge transitions of care across providers and sites. Through teaching and by example, neurologists can profoundly influence successive generations of clinicians to adopt safer practices, a culture of openness, and enhanced professionalism. The federal Safety and Quality Improvement Act of 2005, once implemented, should increase the evidence basis for safer care through voluntary, legally protected reporting of errors and adverse events within the framework of patient safety organizations.

Toward a more efficient and effective neurologic examination for the 21st century.

Practice pressures and quality improvement require greater efficiency and effectiveness in the neurologic examination. I hypothesized that certain ‘marginal’ elements of the examination rarely add value and that ‘core’ elements, exemplified by the plantar response (Babinski), are too often poorly performed or interpreted. I analyzed 100 published, neurologic clinicopathologic conferences (CPCs) and 180 ambulatory neurologic consultations regarding 13 hypothetically ‘marginal’ examination components (including ‘frontal’ reflexes, olfaction, jaw strength, corneal reflex, etc.); also, 120 exams on medical inpatients with neurologic problems, recording definitive errors. I surveyed the recalled practices of 24 non‐neurologists and reviewed the literature for relevant data or guidance. In the CPCs the ‘marginal’ elements of the examination were rarely provided, requested, or used diagnostically, nor did they contribute in the 180 ambulatory consultations. In the chart review errors and omissions dominated testing of plantar responses, with missed Babinski signs in 14% of all cases and 77% of patients with Babinski signs. House officers harbored unrealistic expectations for performance of ‘marginal’ examination elements. Most textbooks omit detailed guidance (and none cite evidence) on achieving greater efficiency. Exams should be streamlined, while improving ‘core’ skills. Neurologists should apply evidence to update the exam taught to students and non‐neurologists.

An Integrated Preclerkship Curriculum in Neuroscience, Psychiatry, and Neurology

The study’s objective was to promote understanding of the integration of preclerkship learning in neuroscience, psychiatry, and neurology and to share the authors’ experience with such a program. A dualism, which may have survived in the past for lack of robust evidence of mind-brain relationships, is now increasingly outmoded. Medical school education should reflect the increasing coherence to be found in these fields. The authors describe curricular and course innovations and revisions at Harvard Medical School that have been implemented in successive iterations over the past decade. These changes have depended upon multidisciplinary leadership, planning, and faculty participation, as well as faculty development and closer coordination between classroom- and hospital-based activity. A hybrid, problem-based block course in the second year integrates basic science with neurologic and psychiatric topics that are aligned with practice of relevant clinical skills. The authors have achieved a high level of integration and coordination of these subjects at preclerkship levels in the domains of both knowledge and skills. The students, as well as the faculty, strongly endorse an intellectually coherent and clinically relevant program of integrated preclerkship learning in neuroscience, psychiatry, and neurology.