Building a Fence Around Brain Death: The Shielded-Brain Formulation.

The concept of brain death was proposed more than 50 years ago, and it has been incorporated in laws and clinical practice, but it remains a source of confusion, debate, and litigation. Because of persistent variability in clinical standards and ongoing controversies regarding policies, the Uniform Law Commission, which drafted the Uniform Determination of Death Act in 1980, has appointed a committee to study whether the act should be revised. This article reviews the history of the concept of brain death and its philosophical underpinnings, summarizes the objections that have been raised to the prevailing philosophical formulations, and proposes a new formulation that addresses those objections while preserving current practices.

Longitudinal Qualitative Study of Career Decision-making of First-Year Medical Students: Why Neurology (or Not)?

OBJECTIVE: The growing shortage of neurologists is in part due to suboptimal recruitment. Little is known about students' decision making regarding a career in neurology, particularly early in training. Using a longitudinal qualitative approach, we aimed to understand factors that influence first-year medical students' decisions about neurology. METHODS: We conducted 1-on-1 semistructured interviews with 15 first-year medical students at 1 institution before and after the preclinical neurology course (2018-2019). In the first interview, we asked about career intentions, factors likely to influence specialty choice, and perceptions of neurology. In the second interview, we asked about changes in students' views over the year. Using thematic analysis, we generated codes and clustered coded data into themes. RESULTS: The 2 most prominent factors influencing career choice in general were lifestyle and personal interest. No students expressed concerns about lifestyle in neurology. Most students were neutral about neurology or had a positive personal interest, which typically increased after the neurology course. Students frequently worried about content difficulty and the curative potential of neurology. CONCLUSIONS: Interventions should include early education about the factors important to students in determining specialty choice, including lifestyle, and address potentially negative perceptions of neurology. Increasing time allotment to the preclinical neurology course may combat perception of the content as difficult.

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.

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.

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.

Does Reducing Clerkship Lengths by 25% Affect Medical Student Performance and Perceptions?

PURPOSE: Transforming a medical school curriculum wherein students enter clerkships earlier could result in two cohorts in clerkships simultaneously during the transition. To avoid overlapping cohorts at the University of Michigan Medical School, the length of all required clerkships was decreased by 25% during the 2016-2017 academic year, without instituting other systematic structural changes. The authors hypothe sized that the reduction in clerkship duration would result in decreases in student perfor mance and changes in student perceptions. METHOD: One-way analyses of variance and Tukey post hoc tests were used to compare the 2016-2017 shortened clerkship cohort with the preceding traditional clerkship cohorts (2014-2015 and 2015-2016) on the following student outcomes: National Board of Medical Examiners (NBME) subject exam scores, year-end clinical skills exam scores, evaluation of clerkships, perceived stress, resiliency, well-being, and perception of the learning environment. RESULTS: There were no significant differences in performance on NBME subject exams between the shortened clerkship cohort and the 2015-2016 traditional cohort, but scores declined significantly over the three years for one exam. Perceptions of clerkship quality improved for three shortened clerkships; there were no significant declines. Learning environment perceptions were not worse for the shortened clerkships. There were no significant differences in performance on the clinical skills exam or in perceived stress, resiliency, and well-being. CONCLUSIONS: The optimal clerkship duration is a matter of strong opinion, supported by few empirical data. These results provide some evidence that accelerating clinical education may, for the studied outcomes, be feasible.

Education Research: unsatisfactory NEX rating correlations: searching for the reasons.

OBJECTIVES: To determine whether the previously demonstrated poor correlation between local faculty and external American Board of Psychiatry and Neurology (ABPN) examiners evaluating the Neurology Evaluation Exercise (NEX) is attributable to a difference between raters who know the residents and raters who do not, a difference between raters with ABPN experience and raters without it, or some other factor. METHODS: Deidentified NEX encounters were videotaped at 2 neurology residency programs. Each video was graded by 1 local faculty examiner, 1 external faculty examiner with ABPN experience, and 1 external faculty examiner without ABPN experience, using the ABPN-sanctioned form. Acceptable/unacceptable rates were compared using Cohen κ statistic. RESULTS: Fifty-eight videotaped NEX encounters involving 20 residents were evaluated by 12 local faculty examiners, 13 ABPN examiners, and 10 external non-ABPN examiners. The level of agreement between groups failed to meet our target κ of 0.7 (ABPN vs non-ABPN external examiners: κ = 0.47 [95% confidence interval 0.21-0.73]; local vs non-ABPN external examiners: κ = 0.37 [95% confidence interval 0.08-0.66]; local vs ABPN external examiners: κ = 0.40 [95% confidence interval 0.14-0.67]). Local, non-ABPN, and ABPN examiners assigned a failing grade to 13 (22%), 11 (19%), and 16 (28%) of the NEX encounters, respectively. CONCLUSIONS: The disappointing correlation between local examiners, non-ABPN external examiners, and ABPN external examiners is not solely attributable to bias toward familiar residents. Inadequate training in NEX administration and scoring could be a factor. It is also possible that the NEX is not a valid tool. Further study is necessary.

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.

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.

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.

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.