Neurology Residency Programs Research Articles

Increasing Resident Satisfaction with Continuity Clinic in Adult Neurology and Internal Medicine Residency Programs through Block Scheduling (588)

Increasing Resident Satisfaction with Continuity Clinic in Adult Neurology and Internal Medicine Residency Programs through Block Scheduling (588)

Wellness Initiative Societies Empowering Residents (WISER): Reflections on Establishing a Wellness Curriculum in a Child Neurology Residency Program (2635)

Wellness Initiative Societies Empowering Residents (WISER): Reflections on Establishing a Wellness Curriculum in a Child Neurology Residency Program (2635)

An online curriculum in movement disorders for neurology housestaff

IntroductionIn many neurology residency programs, outpatient neurology subspecialties are underrepresented. Trainee exposure to these subspecialties, including movement disorders, is limited by paucity and variability of clinical experiences. We designed a structured educational tool to address this variability and allow for standardization of elements of movement disorders teaching. MethodsWe designed and implemented a web-based curriculum in movement disorders for neurology housestaff, in order to improve participant knowledge. The curriculum includes an introduction with a structured framework for the description of abnormal movements and 10 interactive modules focusing on common movement disorders. The curriculum was piloted with nine neurology housestaff at Yale-New Haven Hospital. Evaluation of the curriculum was performed using pre- and post-tests, a survey, and semi-structured interviews. ResultsThe mean pre-test score was 0.7 (±0.19), and the mean post-test score was 0.95 (±0.05) (t = 3.27). Surveys demonstrated mean Likert values >4/5 for all questions in all categories (knowledge acquisition, quantity, enthusiasm and technical). Semi-structured interviews revealed the following themes: 1) the modules increased participant comfort with the topic, 2) the format was engaging, and 3) the curriculum accommodated different learning styles. All participants remarked that the structured framework was a particular strength. ConclusionWe have created, implemented, and evaluated a foundational curriculum in movement disorders for neurology trainees, using readily-available technology. Housestaff responded positively to the curriculum, both in terms of content and format. This curriculum can be implemented in a variety of educational settings, as a central component of a standardized approach to movement disorders teaching.

21. ESTABLISHING THE RESIDENT ACADEMIC PROJECT TO INCREASE SCHOLASTIC ACTIVITY AMONG PEDIATRIC RESIDENTS

Introduction Participation in scholarly activity is a critical element of clinicians’ training. Required research projects are becoming increasingly more common among medical schools and residency programs. The University of California, San Diego (UCSD) pediatric residency program aims to increase research participation among its residents by launching and evaluating a new Resident Academic Project (RAP Project). Methods The RAP Project will be initiated starting with the UCSD pediatric residency class of 2021. The RAP Project is introduced during the fall of their first year. In the spring of their first year, residents will attend an afternoon-long research session that will connect them to potential mentors within each available research area (basic science, clinical, quality improvement (QI), education, and advocacy/global health research). Residents will select a project chair and two committee members and, with the help of their chosen mentor, develop a research proposal. Proposals will be approved by each trainee's research committee as well as the RAP oversight board by the beginning of their second year of residency. Residents will complete their project within the two months prior to graduation, submitting a yearly update at the end of their second year. Residents will present their work at an annual research day at the end of residency. Conclusions A pediatric and adult neurology residency program found that requiring residents to participate in mentored projects aimed at producing peer-reviewed publications or conference presentations increased research productivity among residents as well as expanded its pool of research mentors. 1 We will use baseline data from previous residency classes to determine if the Resident Academic Project increases scholastic activity (peer-reviewed publications, conference participation, ongoing projects) among UCSD pediatric residents and if it increases residents’ satisfaction with their research opportunities during training. We will also create a database of research opportunities, funding sources, and mentors to continue to make the scholastic experience among pediatric residents more robust.

The Role of EEG in the Erroneous Diagnosis of Epilepsy.

Errors in diagnosis are relatively common in medicine and occur in all specialties. The consequences can be serious for both patients and physicians. Errors in neurology are often because of the overemphasis on 'tests' over the clinical picture. The diagnosis of epilepsy in general is a clinical one and is typically based on history. Epilepsy is more commonly overdiagnosed than underdiagnosed. An erroneous diagnosis of epilepsy is often the result of weak history and an 'abnormal' EEG. Twenty-five to 30% of patients previously diagnosed with epilepsy who did not respond to initial antiepileptic drug treatment do not have epilepsy. Most patients misdiagnosed with epilepsy turn out to have either psychogenic nonepileptic attacks or syncope. Reasons for reading a normal EEG as an abnormal one include over-reading normal variants or simple fluctuations of background rhythms. Reversing the diagnosis of epilepsy is challenging and requires reviewing the 'abnormal' EEG, which can be difficult. The lack of mandatory training in neurology residency programs is one of the main reasons for normal EEGs being over-read as abnormal. Tests (including EEG) should not be overemphasized over clinical judgment. The diagnosis of epilepsy can be challenging, and some seizure types may be underdiagnosed. Frontal lobe hypermotor seizures may be misdiagnosed as psychogenic events. Focal unaware cognitive seizures in elderly maybe be blamed on dementia, and ictal or interictal psychosis in frontal and temporal lobe epilepsies may be mistaken for a primary psychiatric disorder.

Surveying the Clinical Learning Environment in Terms of Wellness, Burnout, Psychological Safety, and Mistreatment in a Neurology Residency Program at an Academic Medical Centre (P2.9-027)

Surveying the Clinical Learning Environment in Terms of Wellness, Burnout, Psychological Safety, and Mistreatment in a Neurology Residency Program at an Academic Medical Centre (P2.9-027)

Advocacy education in neurology residency: A survey of U.S. neurology residency program directors (P2.9-016)

Advocacy education in neurology residency: A survey of U.S. neurology residency program directors (P2.9-016)

Abstract WP391: Survey of Neurology Post-Graduate Trainees' Exposure to Interventional Neurology: Report From the Society of Vascular and Interventional Neurology Education Committee

Introduction: Exposure to Interventional Neurology (IN) for Neurology trainees varies from site to site and from year to year, depending on training program needs, political climate, and trainee interest. With new stroke trials expanding the indications and manpower needs for endovascular stroke therapy (EST), we sought to determine the current exposure of Neurology residents and fellows to the burgeoning field. Methods: Neurology residency and Vascular Neurology (VN) fellowship programs were identified from the ACGME database available online. Electronic surveys were distributed to Neurology residency program directors and Vascular Neurology fellowship directors for further distribution to their trainees. Results: A total of 250 programs were invited to participate, from which 76 trainees completed the survey. A range of training levels was captured (22% PGY2, 40% PGY3/4, 30% VN fellows). 72% of respondents had >4 months of exposure to VN in their residency training, though exposure to NeuroICU was less (majority <3 mo). Over 68% of respondents had no exposure to IN, and none had >2 months. Respondents overall felt comfortable with acute stroke treatment decisions, with 60% comfortable or very comfortable with IV tPA decisions and 86% for EST in both early and late windows. While 65% of respondents felt welcomed in the angiography suite and 72% felt a background in Neurology is a good preparation for the field, only 41% agreed that pursuing training and a career in IN is straightforward. Conclusion: Neurology trainees and VN fellows have limited residency exposure to IN, and while most feel well prepared for the field, less than half feel that access to a career in IN is readily available. Efforts to expand exposure to IN and creating consistent pathways for training will be paramount to address the current and urgent patient care needs for EST.

Education Research: Neuroradiology curriculum in neurology residency training programs: How we teach neuroimaging.

To better understand how the essential skill of interpreting various neuroimaging studies is taught to neurology residents in Accreditation Council for Graduate Medical Education (ACGME)-accredited training programs. A 22-question survey was sent electronically to 150 ACGME adult neurology program directors. We collected data regarding the presence of a neuroimaging curriculum, frequency of review sessions and testing, resource availability, and program director confidence in neuroimaging skills of graduating residents. We collected average scores on the neuroimaging section of the Resident In-service Training Examination of graduating residents for the past 3 years, which we attempted to correlate with resource availability. One-third of neurology residency programs do not have a neuroimaging curriculum, and half of training programs do not require a neuroimaging rotation. On average, trainees spend 1 hour per week reviewing imaging with radiologists. Program directors believed trainees receive insufficient neuroimaging training, with a median satisfaction rating on a Likert scale (0-100) of 35 (interquartile range 27-47). Few programs take advantage of online training resources. Opportunities exist to improve neuroimaging education in neurology resident education. This can be done by closer adherence to the American Academy of Neurology neuroimaging curriculum guidelines, especially by expanding access to online resources and additional emphasis on imaging review with neurology subspecialists.

Reader response: Education research: The current state of neurophysiology education in selected neurology residency programs.

I read with interest the Resident & Fellow Education Research article by Daniello and Weber1 on the current state of neurophysiology education in neurology residency programs. The authors found that the majority of residents graduate without meeting level 4 Accreditation Council for Graduate Medical Education (ACGME) milestones in EEG and EMG (EMG > EEG). Inpatient service demands and time constraints on residents were reported as the major cause of resident failure to meet ACGME milestones. The last few decades have witnessed a knowledge explosion in neurology. Somehow, the knowledge explosion and knowledge divide needs to be bridged, especially by residents in training. The 80-hour work week restriction placed by ACGME needs to be relaxed so that residents can be exposed to various neurology subspecialties, or we risk having many of our patients with epilepsy and neuromuscular disorders receive suboptimal care from these doctors in the future.

Editors' note: Education research: The current state of neurophysiology education in selected neurology residency programs

Based on a survey of program directors and residents, Drs. Daniello and Weber reported in “Education research: The current state of neurophysiology education in selected neurology residency programs” that up to a quarter of graduating residents are neither proficient nor confident at EEG and EMG interpretation. The most commonly cited obstacle to learning about electrophysiology was time. In response, Dr. Sethi notes that the 80-hour work week rule needs to be relaxed. However, residents also reported lack of interest in electrophysiology. Drs. Daniello and Weber optimistically believe this may simply be the result of a lack of knowledge and that incorporating electrophysiology training early in residency, particularly in EMG, would help foster interest and thereby improve confidence and proficiency in EEG and EMG interpretation. Based on a survey of program directors and residents, Drs. Daniello and Weber reported in “Education research: The current state of neurophysiology education in selected neurology residency programs” that up to a quarter of graduating residents are neither proficient nor confident at EEG and EMG interpretation. The most commonly cited obstacle to learning about electrophysiology was time. In response, Dr. Sethi notes that the 80-hour work week rule needs to be relaxed. However, residents also reported lack of interest in electrophysiology. Drs. Daniello and Weber optimistically believe this may simply be the result of a lack of knowledge and that incorporating electrophysiology training early in residency, particularly in EMG, would help foster interest and thereby improve confidence and proficiency in EEG and EMG interpretation.

Pediatric Neurocritical Care: Evolution of a New Clinical Service in PICUs Across the United States

Pediatric neurocritical care as a conceptual service is relatively new, and implementation of such specialized services may improve outcomes for children with disorders of the brain or spinal cord. How many pediatric neurocritical care services currently exist in the United States, and attitudes about such a service are unknown. Web-based survey, distributed by e-mail. Survey was sent to PICU Medical Directors and Program Directors of Pediatric Neurosurgery fellowship and Child Neurology residency programs. None. None. A total of 378 surveys were distributed; 161 respondents representing 128 distinct hospitals completed the survey (43% response rate). Thirty-five percent (45/128) reported having a pediatric neurocritical care service. The most common type of service used a consultation model (82%; 32/39 responses). Other types of services were intensivist-led teams in the PICU (five hospitals) and dedicated PICU beds (two hospitals). Hospital characteristics associated with availability of pediatric neurocritical care services were level 1 trauma status (p = 0.017), greater numbers of PICU beds (χ [6, n = 128] = 136.84; p < 0.01), and greater volume of children with pediatric neurocritical care conditions (χ [3, n = 128] = 20.16; p < 0.01). The most common reasons for not having a pediatric neurocritical care service were low patient volume (34/119 responses), lack of subspecialists (30/119 responses), and lack of interest by PICU faculty (25/119 responses). The positive impacts of a pediatric neurocritical care service were improved interdisciplinary education/training (16/45 responses), dedicated expertise (13/45 responses), improved interservice communication (9/45 responses), and development/implementation of guidelines and protocols (9/45 responses). The negative impacts of a pediatric neurocritical care service were disagreement among consultants (2/45 responses) and splitting of the PICU population (2/45 responses). At least 45 specialized pediatric neurocritical care services exist in the United States. Eighty percent of these services are a consultation service to the PICU. Hospitals with level 1 trauma status, greater numbers of PICU beds, and greater numbers of patients with pediatric neurocritical care conditions were associated with the existence of pediatric neurocritical care as a clinical service.

Medical Ethics Education for Neurology Residents: Where Do We Go from Here?

Neurologists regularly confront complex clinical scenarios that require the application of ethical principles to achieve a respectful and fair resolution. In this article, we describe the types of ethically precarious scenarios neurologists encounter, the current status of standards for ethics and communication training for neurology residents, and the present practice of ethics training in neurology residency programs. We make recommendations for optimizing bioethics training for neurology residents and suggest methods for assessing the efficacy of these training initiatives. We emphasize the current need for strengthening the practical bioethics skills of neurologists.

Timing of milestone competency acquisition in neurology residency: What by when?

To determine the stage of training at which neurology residents should achieve individual elements of the Accreditation Council for Graduate Medical Education neurology Milestones and to examine the relationship between perceived importance of Milestones and the stage by which they should be achieved. A modified Delphi technique was used to establish consensus postgraduate year (PGY) expectations for neurology Milestone competencies across 3 geographically and administratively distinct Mayo Clinic neurology residency programs. Timing expectations were examined for relationships to perceived importance of the individual Milestones and effects of participant characteristics. PGY expectations for neurology Milestone elements ranged from PGY 1.3 to PGY 4.1. Extent of rater educational seniority had no effect on PGY competency expectations. There was a moderate inverse relationship between perceived importance of the Milestone element and the PGY by which it should be achieved (r s = -0.74, p < 0.0001). Expectations for neurology Milestone competency acquisition can be measured and may help inform individual program design, educational expectations, and future Milestone design.

What's happening in Without Borders

We are aware of the increasing shortage of neurologists practicing in the United States,1 but in some low- and middle-income countries (LMIC), such as Cambodia, the number of practicing specialists may be in the single digits. In a recent Global stuff you should know titled “Bringing neuroscience to Cambodia,” Dr. Soma Sahai-Srivastava outlined the need for her summer teaching program and follows with information on the program that will begin its 5th year in July 2018. “In my many trips to Cambodia in the last decade, volunteering solo, I realized that there are no short-term volunteering opportunities for neurology clinical care, unlike other specialties like emergency medicine, pediatrics, surgery, etc. No neurology outpatient clinics or inpatient specialized programs existed until recently. There were only 3 neurologists in the country in 2012.2 The first internal medicine residency program launched in 2011 and there are still no adult or pediatric neurology residency programs. There is one pediatric neurosurgeon and no pediatric neurologists in the entire country. There is a lack of commonly prescribed neurologic medications (e.g., phenytoin and phenobarbital are the only antiepileptics available at the public hospitals). Under these circumstances, I realized that rather than volunteering in clinics treating individual patients, the first priority was neuroscience education and curriculum development at all levels: undergraduate, medical school, and postgraduate.”

A Needs Assessment of Palliative Care Education among the United States Adult Neurology Residency Programs.

Palliative care (PC) needs in patients with neurological diseases are becoming more recognized by neurologists and PC physicians. To qualify and quantify the PC education available in the United States adult neurology programs since the Accreditation Council for Graduate Medical Education (ACGME) published updated mandates in 2009. A 22-question survey was electronically distributed to each neurology residency program in the United States. All program directors (PDs) and assistant/associate program directors (APDs) of adult neurology programs. This study had a 35% survey response rate (49 programs). Of the participating programs, 20% offer no PC education to residents. Communication, prognostication, and withdrawing life-prolonging therapies were the domains identified as the most important for resident education; these were also the domains PDs/APDs were most comfortable providing for their own patients, and the domains their residents are the best trained in currently. Addressing spiritual distress was the domain considered the least important, the domain PDs/APDs were least comfortable providing for their own patients, and the domains residents are currently the least well-trained in. Forty-two percent of programs were dissatisfied with the PC education available at their program. Time for teaching, availability of faculty, and faculty expertise were the most common barriers. PC education varies greatly across the United States adult neurology residency programs despite ACGME requirements. As time and resources limit current training, utilization of interdisciplinary educational teams and nationally available PC educational material may improve implementation of PC education in these residency programs.

Education Research: Resident education through adult learning in neurology: Implementation and impact.

To enhance residency education by implementing the 6 principles of adult learning theory (ALT) in a large academic neurology residency program. We implemented a set of curricular interventions aimed at Resident Education through Adult Learning in Neurology (REAL Neurology), in a large, academic neurology residency program. Interventions included didactic reform, increasing resident-as-teacher activities, and enhancing residents' interaction. The primary outcome was the change in mean Residency In-service Training Examination (RITE) percentile between the preintervention and postintervention cohorts, adjusting for US Medical Licensing Examination step 1 and 2 score. Other analysis included evaluating the effect of the duration of intervention exposure on outcome and evaluating the intervention effect on the proportion of advanced performers. A total of 134 RITE score reports were evaluated (87 preintervention and 47 postintervention). The mean RITE score percentile postintervention was 11.7 points higher than preintervention (adjusted, longitudinal analysis: fit linear mixed model, p < 0.0001). Postgraduate year 3 learners who had 1 and 2 years of exposure scored 13.4 and 18.9 points higher than those with no exposure at all, respectively (analysis of covariance, p = 0.04). The adjusted odds of better performance with REAL Neurology was 5.77 (ordinal logistic regression, 95% confidence interval 2.37-14.07, p < 0.05). This study evaluated the efficacy and feasibility of an ALT-based curricular program in neurology education. The results show robust and sustainable benefit for residents in training without imposing a financial or logistical burden on programs. REAL Neurology could serve as a model for curricular reform in other programs across subspecialties.

Reader response: Residency training: The need for an integrated diversity curriculum for neurology residency

I read with interest Drs. Rosendale and Josephson's1 experience with the development and introduction of an integrated diversity curriculum within their neurology residency program. Through a recent experience, I realized the unmet need for cultural responsiveness training not just in the neurology residencies, but in the entire US health care system. A woman from the United Arab Emirates was admitted to the epilepsy monitoring unit (EMU) for intracranial EEG monitoring and resective epilepsy surgery. As per standing protocols of the EMU, it was recommended that she remain in bed at all times and use a bedpan for toileting. The next day, the overnight nurse told me that the patient became acutely agitated, requiring multiple doses of IV Haldol and Ativan to calm her down. Upon questioning the family, I realized that the cause of her agitation was the denial of the use of the bathroom and insistence of the hospital staff that she use a bedpan. Laws of Islam concerning ritual purity and cleanliness recommend steps be taken to avoid being soiled and defiled by urine and feces. Once the patient was allowed the use of a bedside commode, under close nursing supervision, her agitated behavior resolved.

Education Research: Variation in priorities for neurocritical care education expressed across role groups.

To define expectations for neurocritical care (NCC) core competencies vs competencies considered within the domain of other subspecialists. An electronic survey was disseminated nationally to NCC nurses, physicians, fellows, and neurology residents through Accreditation Council for Graduate Medical Education neurology residency program directors, United Council for Neurologic Subspecialties neurocritical care fellowship program directors, and members of the Neurocritical Care Society. A total of 268 neurocritical care providers and neurology residents from 30 institutions responded. Overall, >90% supported NCC graduates independently interpreting and managing systemic and cerebral hemodynamic data, or performing brain death determination, neurovascular ultrasound, vascular access, and airway management. Over 75% endorsed that NCC graduates should independently interpret EEG and perform bronchoscopies. Fewer but substantial respondents supported graduates being independent performing intracranial bolt (45.8%), ventriculostomy (39.0%), tracheostomy (39.8%), or gastrostomy (19.1%) procedures. Trainees differed from physicians and program directors, respectively, by advocating independence in EEG interpretation (92.8%, 61.8%, and 65.3%) and PEG placement (29.3%, 9.1%, and 8.5%). Broad support exists across NCC role groups for wide-ranging NCC competencies including skills often performed by other neurology and non-neurology subspecialties. Variations highlight natural divergences in expectations among trainee, physician, and nurse role groups. These results establish expectations for core competencies within NCC and initiate dialogue across subspecialties about best practice standards for the spectrum of critically ill patients requiring neurologic care.

Movement Disorders Video Curriculum for Neurology Clerkships and Residency Programs (P2.006)

Movement Disorders Video Curriculum for Neurology Clerkships and Residency Programs (P2.006)