Educating Residents and Students in the Clinic.

Training of students and residents in outpatient settings requires adequate exposure to a broad range of neurologic diseases. A competency-based method has been frequently used to provide a framework for the design and assessment of medical curriculums. However, it is the responsibility of the faculty within a medical school to design the curriculum and ensure its quality. In this article, we review learning objectives, assessment of core competencies, the current status of outpatient neurology education, and the flaws that may affect its quality. We also discuss potential strategies and approaches for the improvement of education and learning process in the outpatient setting, including early clinical exposure of students, cross-disciplinary courses, balancing case mix, near-peer teaching, active learning, electronic and online education, and virtual modules.

Accelerated Implementation of a Virtual Neurology Clerkship Amid a Global Crisis.

The standard neurology clinical experience in medical school focuses primarily on bedside patient encounters; however, the limitations of the clinical environment due to the current COVID-19 pandemic have accelerated the need for virtual curriculum development. To provide guidance to Neurology clerkship directors during this unprecedented time, the American Academy of Neurology (AAN) Undergraduate Education Subcommittee (UES) formed a workgroup to develop an outline for a virtual curriculum, provide recommendations, and describe models of integrating virtual curricula into the neurology clerkship. In this overview, we discuss different methods of virtual instruction, hybrid models of clerkship training and the challenges to its implementation, professionalism issues, and modification of feedback and assessment techniques specific to the virtual learning environment. We also offer suggestions for implementation of a hybrid virtual curriculum into the neurology clerkship. The virtual curriculum is intended to supplement the core neurology in-person clinical experience and should not be used for shortening or replacing the required neurology clinical clerkship.

Contemporary Neuroscience Core Curriculum for Medical Schools.

Medical students need to understand core neuroscience principles as a foundation for their required clinical experiences in neurology. In fact, they need a solid neuroscience foundation for their clinical experiences in all other medical disciplines also, because the nervous system plays such a critical role in the function of every organ system. Due to the rapid pace of neuroscience discoveries, it is unrealistic to expect students to master the entire field. It is also unnecessary, as students can expect to have ready access to electronic reference sources no matter where they practice. In the pre-clerkship phase of medical school, the focus should be on providing students with the foundational knowledge to use those resources effectively and interpret them correctly. This article describes an organizational framework for teaching the essential neuroscience background needed by all physicians. This is particularly germane at a time when many medical schools are re-assessing traditional practices and instituting curricular changes such as competency-based approaches, earlier clinical immersion, and increased emphasis on active learning. This article reviews factors that should be considered when developing the pre-clerkship neuroscience curriculum, including goals and objectives for the curriculum, the general topics to include, teaching and assessment methodology, who should direct the course, and the areas of expertise of faculty who might be enlisted as teachers or content experts. These guidelines were developed by a work group of experienced educators appointed by the Undergraduate Education Subcommittee (UES) of the American Academy of Neurology (AAN). They were then successively reviewed, edited, and approved by the entire UES, the AAN Education Committee, and the AAN Board of Directors.

Expectations of and for Clerkship Directors 2.0: A Collaborative Statement from the Alliance for Clinical Education.

This article presents an update of the collaborative statement on clerkship directors (CDs), first published in 2003, from the national undergraduate medical education organizations that comprise the Alliance for Clinical Education (ACE). The clerkship director remains an essential leader in the education of medical students on core clinical rotations, and the role of the CD has and continues to evolve. The selection of a CD should be an explicit contract between the CD, their department, and the medical school, with each party fulfilling their obligations to ensure the success of the students, the clerkship and of the CD. Educational innovations and accreditation requirements have evolved in the last two decades and therefore this article updates the 2003 standards for what is expected of a CD and provides guidelines for the resources and support to be provided.In their roles as CDs, medical student educators engage in several critical activities: administration, education/teaching, coaching, advising, and mentoring, faculty development, compliance with accreditation standards, and scholarly activity. This article describes (a) the work products that are the primary responsibility of the CD; (b) the qualifications for the CD; (c) the support structure, resources, and personnel that are necessary for the CD to accomplish their responsibilities; (d) incentives and career development for the CD; and (e) the dedicated time that should be provided for the clerkship and the CD to succeed. Given all that should rightfully be expected of a CD, a minimum of 50% of a full-time equivalent is recognized as appropriate. The complexity and needs of the clerkship now require that at least one full-time clerkship administrator (CA) be a part of the CD's team.To better reflect the current circumstances, ACE has updated its recommendations for institutions and departments to have clear standards for what is expected of the director of a clinical clerkship and have correspondingly clear guidelines as to what should be expected for CDs in the support they are provided. This work has been endorsed by each of the eight ACE member organizations.

Funding the Educational Mission in Neurology.

Although it is self-evident that education in neurology is important and necessary, how to fund the educational mission is a frequent challenge for neurology departments and clinicians. Department chairs often resort to a piecemeal approach, cobbling together funding for educators from various sources, but frequently falling short. Here, we review the various sources available to fund the educational mission in neurology, understanding that not every department will have access to every source. We describe the multiple different teaching models and formats used by the modern student and educator and their associated costs, some of which are exorbitant. We discuss possible nonfinancial incentives, including pathways to promotion, educational research, and other awards and recognition. Neurological education is commonly underfunded, and departments and institutions must be nimble and creative in finding ways to fund the time and effort of educators.

Attracting neurology's next generation: A qualitative study of specialty choice and perceptions.

OBJECTIVES: To better understand the reasons medical students select or avoid a career in neurology by using a qualitative methodology to explore these factors, with the long-term objective of attracting more graduates to the field. METHODS: In 2017, 27 medical students and 15 residents participated in 5 focus groups, and 33 fourth-year medical students participated in semistructured individual interviews. Participants were asked predefined open-ended questions about specialty choice, experiences in their basic neuroscience course and neurology clerkship, and perceptions about the field. Interviews were audio recorded and transcribed. We used a flexible coding methodology to generate themes across groups and interviews. RESULTS: Four main analytical themes emerged: (1) early and broad clinical exposure allows students to "try on" neurology and experience the variety of career options; (2) preclerkship experiences and a strong neuroscience curriculum lay the foundation for interest in the field; (3) personal interactions with neurology providers may attract or deter students from considering the specialty; and (4) persistent stereotypes about neurologists, neurology patients, and treatment options harm student perceptions of neurology. CONCLUSION: Efforts to draw more students to neurology may benefit from focusing on clinical correlations during preclerkship neuroscience courses and offering earlier and more diverse clinical experiences, including hands-on responsibilities whenever possible. Finally, optimizing student interactions with faculty and residents and reinforcing the many positive aspects of neurology are likely to favorably affect student perceptions.

Residency Training: A practical guide for medical students who are planning a future in neurology.

Medical students choose neurology for many reasons, including interest in neuroscience, the intellectual challenge of diagnosing and treating disorders of the nervous system, and the opportunity for continuity of care. Neurologists have great flexibility in choice of practice environment, ranging from an exclusively inpatient setting to a strictly clinic-based practice. The purpose of this article is to provide practical, actionable, systematic advice for medical students at every level of training on how to prepare for a neurology residency application and a career in neurology. To this end, we include a timeline designed to guide students' efforts throughout their medical school education. These recommendations incorporate the viewpoints of key participants in many aspects of medical student and resident neuroscience education. The timeline and recommendations outline a suggested early, proactive approach, but should not discourage students from considering neurology at a later point in their training. Neurology remains an inclusive specialty that welcomes students of all backgrounds and offers a rewarding career in one of the most exciting fields in medicine.

Telemedicine in neurology: Telemedicine Work Group of the American Academy of Neurology update.

PURPOSE: While there is strong evidence supporting the importance of telemedicine in stroke, its role in other areas of neurology is not as clear. The goal of this review is to provide an overview of evidence-based data on the role of teleneurology in the care of patients with neurologic disorders other than stroke. RECENT FINDINGS: Studies across multiple specialties report noninferiority of evaluations by telemedicine compared with traditional, in-person evaluations in terms of patient and caregiver satisfaction. Evidence reports benefits in expediting care, increasing access, reducing cost, and improving diagnostic accuracy and health outcomes. However, many studies are limited, and gaps in knowledge remain. SUMMARY: Telemedicine use is expanding across the vast array of neurologic disorders. More studies are needed to validate and support its use.

Characteristics of graduating US allopathic medical students pursuing a career in neurology.

OBJECTIVES: To identify factors associated with medical students becoming neurologists because, despite the increasing burden of neurologic disorders, there is a growing neurologist shortage. METHODS: Deidentified data from the Association of American Medical Colleges Matriculating Student Questionnaire (MSQ) and Graduation Questionnaire (GQ) were obtained for the graduation years 2013 to 2014 through 2016 to 2017. Logistic regression was used to assess demographic characteristics and responses to training and career-related questions in association with specialty choice (intent to enter neurology). RESULTS: Of the 51,816 students with complete data, 1,456 (2.8%) indicated an intent to enter a neurology residency. Factors associated with an increased likelihood of entering neurology were a student's rating of excellent for their basic neuroscience course and neurology clerkship, participation in an MD/PhD program, majoring in neuroscience or psychology as an undergraduate, a selection response of "content of the specialty was a strong influence on career choice," and indicating interest in neurology on the MSQ. Factors associated with a decreased likelihood of entering neurology were a higher-priority response on the GQ for salary, work/life balance, and personal fit of the specialty. CONCLUSION: Data from surveys at the entry into and graduation from medical school suggest several approaches to increase the number of medical students entering neurology, including a focus on the student-reported quality of the basic neuroscience course and neurology clerkships, targeted engagement with MD/PhD students, and mentoring programs for students interested in neurology. Efforts to improve salaries for neurologists, to reduce medical school debt, and to improve work/life balance may also help to attract more students.

Core curriculum guidelines for a required clinical neurology experience.

Physicians in most specialties frequently encounter patients with neurologic conditions. For most non-neurologists, postgraduate neurologic education is variable and often limited, so every medical school's curriculum must include clinical learning experiences to ensure that all graduating medical students have the basic knowledge and skills required to care for patients with common neurologic symptoms and neurologic emergencies. In the nearly 20 years that have elapsed since the development of the initial American Academy of Neurology (AAN)-endorsed core curriculum for neurology clerkships, many medical school curricula have evolved to include self-directed learning, shortened foundational coursework, earlier clinical experiences, and increased utilization of longitudinal clerkships. A workgroup of both the Undergraduate Education Subcommittee and Consortium of Neurology Clerkship Directors of the AAN was formed to update the prior curriculum to ensure that the content is current and the format is consistent with evolving medical school curricula. The updated curriculum document replaces the term clerkship with experience, to allow for its use in nontraditional curricular structures. Other changes include a more streamlined list of symptom complexes, provision of a list of recommended clinical encounters, and incorporation of midrotation feedback. The hope is that these additions will provide a helpful resource to curriculum leaders in meeting national accreditation standards. The curriculum also includes new learning objectives related to cognitive bias, diagnostic errors, implicit bias, care for a diverse patient population, public health impact of neurologic disorders, and the impact of socioeconomic and regulatory factors on access to diagnostic and therapeutic resources.

Incorporating sleep medicine content into medical school through neuroscience core curricula.

OBJECTIVE: To present (1) justification for earmarking sleep medicine education as an essential component of all medical school curricula and (2) various avenues to incorporate sleep medicine exposure into medical school curricula through (primarily) neuroscience and neurology courses. METHODS: Per consensus of a team of leading neurology and sleep medicine educators, an evidence-based rationale for including sleep medicine across a 4-year medical school curriculum is presented along with suggested content, available/vetted resources, and formats for delivering sleep medicine education at various points and through various formats. RESULTS: Growing evidence has linked sleep disorders (e.g., sleep-disordered breathing, chronic insufficient sleep) as risk factors for several neurologic disorders. Medical educators in neurology/neuroscience are now strongly advocating for sleep medicine education in the context of neurology/neuroscience pre and post graduate medical education. Sleep medicine education is also a critical component of a proactive strategy to address physician wellness and burnout. The suggested curriculum proposes a sleep educational exposure time of 2-4 hours per year in the form of lectures, flipped-classroom sessions, clinical opportunities, and online educational tools that would result in a 200%-400% increase in the amount of sleep medicine exposure that US medical schools currently provide. The guidelines are accompanied by the recommendation for use of technological education, to facilitate more seamless curricular incorporation. CONCLUSION: Even in this era with limited flexibility to add content to an already packed medical school curriculum, incorporating sleep medicine exposure into the current medical school curriculum is both justified and feasible.

A dozen years of evolution of neurology clerkships in the United States: Looking up.

OBJECTIVE: To report a 2017 survey of all US medical school neurology clerkship directors (CDs) and to compare the results to similar surveys conducted in 2005 and 2012. METHODS: An American Academy of Neurology (AAN) Consortium of Neurology Clerkship Directors (CNCD) workgroup developed the survey that was sent to all neurology CDs listed in the AAN CNCD database. Comparisons were made to similar 2005 and 2012 surveys. RESULTS: The response rate was 92 of 146 programs (63%). Among the responding institutions, neurology is required in 94% of schools and is 4 weeks in length in 75%. From 2005 to 2017, clerkships shifted out of a fourth-year-only rotation (p = 0.035) to earlier curricular time points. CD protected time averages 0.24 full-time equivalent (FTE), with 31% of CDs reporting 0.26 to 0.50 FTE support, a >4-fold increase from prior surveys (p < 0.001). CD service of >12 years increased from 9% in 2005 to 23% in 2017. Twenty-seven percent also serve as division chief/director, and 22% direct a preclinical neuroscience course. Forty-nine percent of CDs are very satisfied in their role, increased from 34% in 2012 (p = 0.046). The majority of CDs identify as white and male, with none identifying as black/African American. CONCLUSION: Changes since 2005 and 2012 include shifting of the neurology clerkship to earlier in the medical school curriculum and an increase in CD salary support. CDs are more satisfied than reflected in previous surveys and stay in the role longer. There is a lack of racial diversity among neurology CDs.

Entrustable professional activities: A useful concept for neurology education.

Medical education is currently undergoing a paradigm shift from process-based to competency-based education, focused on measuring the desired competence of a physician. In an attempt to improve the assessment framework used for medical education, the concept of entrustable professional activities (EPAs) has gained traction. EPAs are defined as professional activities that can be entrusted to an individual in a clinical context. The Association of American Medical Colleges (AAMC) defined a set of 13 such EPAs to define the core of what all students should be able to do on day 1 of residency, regardless of specialty choice. The AAMC is currently piloting these EPAs with 10 medical schools to determine if EPAs can be used as a way to observe, measure, and entrust medical students with core clinical activities by the end of the clinical immersion experiences of the third year. The specialty of pediatrics is piloting the use of specialty-specific EPAs at 5 medical schools to assess readiness for transitions from medical school into pediatric residency training and practice. To date, no neurology-specific EPAs have been published for use in neurology clerkships or neurology residencies. This article introduces the concept of EPAs in the context of competency-based medical education and describes how EPAs might be relevant and applicable in neurologic education across the continuum. The Undergraduate Education Subcommittee of the American Academy of Neurology advocates for a proactive approach to incorporating core EPAs in undergraduate medical education and to considering an EPA-based specialty-specific assessment framework for neurology.

Subchronic toxicity and genotoxicity studies of Antrodia mushroom ß-glucan preparation.

Antrodia cinnamomea is one of the most highly valued mushrooms utilized in traditional Taiwanese therapeutic practices. Its neutral monosaccharides (mannose, glucose and xylose) linked by a ß-D-glucan chain have been claimed to be responsible for its health benefits. The objective of the present study was to investigate adverse effects, if any, of ß-glucan (∼65% pure) from A. cinnamomea in subchronic toxicity and mutagenicity studies. In the subchronic toxicity study, Sprague Dawley rats (12/sex/group) were followed Organization for Economic Cooperation and Development (OECD) test guideline with Good Laboratory Practice (GLP) application, and were administered (gavage) Antrodia mushroom ß-glucan preparation at dose levels of 0, 500, 1000 and 2000 mg/kg body weight (bw)/day for 90 days. Treatment with ß-glucan preparation did not result in any toxicologically significant treatment-related changes in clinical observations, ophthalmic examinations, body weights, body weight gains, feed consumption, and organ weights. The clinical pathology as studied by hematology, serum chemistry, urinalysis or terminal necropsy (gross or histopathology findings) did not reveal any treatment-related adverse effects. The results of mutagenicity studies as evaluated by gene mutations in Salmonella typhimurium, in vitro chromosome aberrations and in vivo micronucleus test in mice did not reveal any genotoxicity of ß-glucan preparation. Based on the subchronic study, the no observed-adverse-effect level (NOAEL) for ß-glucan preparation from Antrodia mushroom was determined as 2000 mg/kg bw/day, the highest dose tested.

Developing an outline for teleneurology curriculum: AAN Telemedicine Work Group recommendations.

The emerging field of teleneurology is delivering quality care to neurologic patients in increasingly numerous technologies and configurations. Teleneurology is well-positioned to address many of the logistical issues neurologists and their patients encounter today. However, formalized medical training has not caught up with this developing field, and there is a lack of formal education concentrating on the specific opportunities and challenges of teleneurology. Considering this, the American Academy of Neurology Telemedicine Work Group identified equivalencies with which any practitioner of teleneurology should be familiar. The purpose of this curriculum is not to define teleneurology or mandate where its use is appropriate, but rather to provide guidance on basic equivalencies that students, residents, and practitioners should know while practicing teleneurology. Comprehensive training in clinical bedside neurology is necessary to safely practice teleneurology and the components of this curriculum are an extension of that training. In this article, we offer a detailed discussion on the rationale for the contents of this curriculum and conclude by providing a model curriculum and an outline for evaluating residents in teleneurology.

McArdle disease: a "pediatric" disorder presenting in an adult with acute kidney injury.

Rhabdomyolysis is characterized by the acute breakdown of skeletal muscle, resulting in the release of muscle cell contents, subsequent myoglobinuria, and in severe cases, acute renal failure. A number of etiologies have been identified in acute rhabdomyolysis, in which drugs and trauma account for the majority of cases. One etiological category that is commonly overlooked in the adult population is an underlying genetic defect. This may be challenging to diagnose due to its rarity in the adult demographic and the marked heterogeneity, often requiring a high level of clinical suspicion before investigation is pursued. Once diagnosed, however, appropriate steps can be taken to reduce future episodes of rhabdomyolysis, further renal injury, and other systemic complications. Here, we report a case of an adult patient presenting with acute rhabdomyolysis secondary to McArdle disease, a genetic disease causing defective glycogenolysis. The case highlights the importance of recognizing the potential of undiagnosed "pediatric" disorders in adulthood and particularly for underlying genetic causes of rhabdomyolysis.

Safety assessment of non-animal chondroitin sulfate sodium: Subchronic study in rats, genotoxicity tests and human bioavailability.

Chondroitin sulfate, an amino sugar polymer made of glucuronic acid and N-acetyl-galactosamine, is used in dietary supplements to promote joint health. Commonly used chondroitin sulfate is of animal origin and can pose potential safety problems including bovine spongiform encephalopathy (BSE). The objective of the present study was to investigate potential adverse effects, if any, of microbial derived chondroitin sulfate sodium (CSS) in subchronic toxicity, genotoxicity and bioavailability studies. In the toxicity study, Sprague Dawley rats (10/sex/group) were gavaged with CSS at dose levels of 0, 250, 500 and 1000 mg/kg body weight (bw)/day for 90-days. No mortality or significant changes in clinical signs, body weights, body weight gain or feed consumption were noted. Similarly, no toxicologically relevant treatment-related changes in hematological, clinical chemistry, urinalysis and organ weights were noted. Macroscopic and microscopic examinations did not reveal treatment-related abnormalities. In vitro mutagenic and clastogenic potentials as evaluated by Ames assay, chromosomal aberration test and micronucleus assay did not reveal genotoxicity of CSS. In pharmacokinetic study in human, CSS showed higher absorption as compared to chondroitin sulfate of animal origin. The results of subchronic toxicity study supports the no-observed-adverse-effect level (NOAEL) for CSS as 1000 mg/kg bw/day, the highest dose tested.

Current Treatment, Emerging Translational Therapies, and New Therapeutic Targets for Autoimmune Myasthenia Gravis.

Myasthenia gravis (MG) is an autoimmune disease associated with the production of autoantibodies against 1) the skeletal muscle acetylcholine receptor; 2) muscle-specific kinase, a receptor tyrosine kinase critical for the maintenance of neuromuscular synapses; 3) low-density lipoprotein receptor-related protein 4, an important molecular binding partner for muscle-specific kinase; and 4) other muscle endplate proteins. In addition to the profile of autoantibodies, MG may be classified according the location of the affected muscles (ocular vs generalized), the age of symptom onset, and the nature of thymic pathology. Immunopathologic events leading to the production of autoantibodies differ in the various disease subtypes. Advances in our knowledge of the immunopathogenesis of the subtypes of MG will allow for directed utilization of the ever-growing repertoire of therapeutic agents that target distinct nodes in the immune pathway relevant to the initiation and maintenance of autoimmune disease. In this review, we examine the pathogenesis of MG subtypes, current treatment options, and emerging new treatments and therapeutic targets.

Safety evaluation of zeaxanthin concentrate (OmniXan™): acute, subchronic toxicity and mutagenicity studies.

The available evidence suggests a beneficial effect of zeaxanthin against the progression of age-related macular degeneration (AMD). The objective of the present study was to investigate potential adverse effects of OmniXan™, a RR-zeaxanthin (65%) enriched product obtained from paprika (Capsicum annum fruits) in subchronic toxicity and mutagenicity studies. The oral LD50 of OmniXan(TM) in rats was greater than 2000 mg/kgbody weight (bw)/day. For the subchronic toxicity study, Wistar rats (10/sex/group) were gavaged daily with zeaxanthin concentrate at doses of 0, 4, 40 and 400 mg/kg bw/day for 90-days. No treatment related clinical signs and mortalities observed. Similarly, no treatment related toxicologically significant changes in body weight, feed consumption; ophthalmoscopic examination, neurological examination, hematology, urine analysis and organ weights were observed. Statistically significant changes observed in some clinical chemistry parameters were considered toxicologically and biologically insignificant and nonadverse. Macroscopic and microscopic examinations did not reveal treatment-related abnormalities. The results of mutagenicity testing using Salmonella typhimurium did not reveal any genotoxicity. The no observed-adverse-effect level (NOAEL) for zeaxanthin concentrate (OmniXan(TM)) was determined as 400 mg/kg bw/day, the highest dose tested. The findings of this subchronic toxicity and mutagenicity studies support safety of zeaxanthin concentrate.