A Guide for Aspiring Neurology Educators.

Deans of medical schools have diverse roles and responsibilities. In this article, we use the career development trajectories of neurologists who have become education deans in student affairs and curriculum to offer advice to aspiring clinician educators of all levels and backgrounds. Although their roles differ, the advice they share is universal and essential for the career development of future clinician educators. ANN NEUROL 2024.

Approach to Headache.

There is a very high prevalence of headache in both outpatient and inpatient settings, in the United States and worldwide, due to an abundance of possible causes. Having a practical and systematic approach to evaluating and treating headache is, therefore, key to making the correct diagnosis, or possibly overlapping diagnoses. Taking a thorough and methodical headache history is the mainstay for diagnosis of both primary and secondary headache disorders. Evaluation and workup should include a complete neurological examination, consideration of neuroimaging in specific limited situations, and serum or spinal fluid analysis if indicated. Adopting a diagnostic approach to headache ensures that cannot-miss, or potentially fatal, headache syndromes are not overlooked, while resource-intensive tests are performed only on an as-needed basis.

The current state of headache medicine education in the United States and Canada: An observational, survey-based study of neurology clerkship directors and curriculum deans.

OBJECTIVE: To investigate the current headache medicine education paradigm in allopathic and osteopathic medical schools in the United States and Canada. BACKGROUND: There is a disparity in the number of clinicians specially trained to treat patients with headache disorders and the number of people who have them. Early education and exposure to headache medicine is crucial to address this disparity. However, the current state of headache education within medical schools across the United States and Canada is unknown. METHODS: The authors created a medical student headache education survey, which is a 20-question REDCap survey that was distributed via email to the neurology clerkship director, curriculum dean, or similar role at each US and Canadian MD or DO conferring medical school. The email listserv was created using the American Academy of Neurology Clerkship Directory, the Association of American Medical Colleges Organization Directory, the American Association of College of Osteopathic Medicine Organization Directory, manual searches of the institutions' websites, and phone calls and emails to administrators as needed. RESULTS: Of the 249 individuals contacted, 78 completed the survey, yielding a response rate of 31.3%. Of those responses, 84.6% of respondents (66/78) reported that their institution has at least one mandatory session on headache disorders. Many of these sessions (72.7% (48/78)) occurred during preclinical training, and 74.2% (49/78) occurred as part of the clinical curricula. Of respondents, 44.9% (39/78) reported that their institutions coordinate headache education across training levels (i.e., from preclinical to clinical), and only 17.9% (14/78) coordinate across clinical rotations. The most common topics covered were headache red flags, migraine, pharmacologic management, and differentiating primary versus secondary headache. 65.4% of respondents (51/78) felt that the preclinical headache curriculum prepares their students for the clinical experience, and 55.1% (43/78) felt that medical students were learning enough about headache medicine at their institution. Barriers to educating medical students about headache included insufficient time during courses, lack of administrative support in curricula development, lack of available resources, and lack of student interest. Case-based learning modules and online lectures were the most desired educational materials to improve medical student headache education at their institution. CONCLUSIONS: The majority of medical schools report incorporating headache medicine education into preclinical or clinical curricula and cover a range of topics in headache medicine. Yet there remains a lack of consistency, with some reporting limited headache education, citing barriers such as lack of administrative support and available educational resources. There is also variation in what is being taught at the medical student level. Future projects should aim to address said barriers, with the goal of providing a standardized headache medicine curriculum for use across medical schools.

Individualized clinical management of patients at risk for Alzheimer's dementia.

INTRODUCTION: Multidomain intervention for Alzheimer's disease (AD) risk reduction is an emerging therapeutic paradigm. METHODS: Patients were prescribed individually tailored interventions (education/pharmacologic/nonpharmacologic) and rated on compliance. Normal cognition/subjective cognitive decline/preclinical AD was classified as Prevention. Mild cognitive impairment due to AD/mild-AD was classified as Early Treatment. Change from baseline to 18 months on the modified Alzheimer's Prevention Cognitive Composite (primary outcome) was compared against matched historical control cohorts. Cognitive aging composite (CogAging), AD/cardiovascular risk scales, and serum biomarkers were secondary outcomes. RESULTS: One hundred seventy-four were assigned interventions (age 25-86). Higher-compliance Prevention improved more than both historical cohorts (P = .0012, P < .0001). Lower-compliance Prevention also improved more than both historical cohorts (P = .0088, P < .0055). Higher-compliance Early Treatment improved more than lower compliance (P = .0007). Higher-compliance Early Treatment improved more than historical cohorts (P < .0001, P = .0428). Lower-compliance Early Treatment did not differ (P = .9820, P = .1115). Similar effects occurred for CogAging. AD/cardiovascular risk scales and serum biomarkers improved. DISCUSSION: Individualized multidomain interventions may improve cognition and reduce AD/cardiovascular risk scores in patients at-risk for AD dementia.

Continuing Medical Education in Neurology.

Continuing medical education (CME) is designed to keep physicians up-to-date on ever-changing practices and guidelines to provide patients with high quality care. CME is especially important in the field of neurology due to rapidly evolving knowledge and medical advances, and is a required element of maintenance of certification. CME itself has evolved from a passive, didactic approach to a learner-centered approach which utilizes new technologies, online learning, and simulations. CME improves knowledge, skills, and, to a lesser extent, patient outcomes, with multimodal, interactive interventions found to be most effective in teaching health care professionals. However, little data are available on CME in neurology. There is a significant gap in knowledge about CME interventions that work for neurologists. Rigorous education research, as well as making effective CME interventions more readily available to neurologists, is critical to optimize lifelong learning of physicians in the field of neurology.

Patterns of adjuvant radiation usage and survival outcomes for stage I endometrial carcinoma in a large hospital-based cohort.

OBJECTIVE: Two randomized trials have demonstrated a local control advantage in the absence of a survival advantage for the addition of adjuvant radiation therapy (RT) to surgery in patients with stage I endometrial adenocarcinoma (EC). This study analyzed the National Cancer Data Base (NCDB) to evaluate the impact of adjuvant RT on overall survival (OS) for patients with stage I EC. METHODS: Patients with EC who underwent total hysterectomy/bilateral salpingo-oophorectomy between 2004 and 2011 were queried. Only those with AJCC stage pT1N0M0 were included. Patients surviving <4months excluded. Adjuvant RT included external beam RT (EBRT), brachytherapy, or external RT+brachytherapy. OS was analyzed using the Kaplan-Meier method. Multivariate Cox regression analysis and propensity matched analysis were performed to assess the impact of covariates on OS. RESULTS: There were 61,697 patients included. Most women (83.9%) did not receive adjuvant RT. Adjuvant RT usage increased with increasing stage/grade. Usage of brachytherapy alone decreased with increasing stage/grade (78.2% for IA/G1 to 36.1% for IB/G3) corresponding to an increase in the use of EBRT (21.8% for IA/G1 to 53.9% for IB/G3). On multivariable analysis, adjuvant EBRT (HR 0.83, 95%CI 0.74-0.93, p=0.002) and brachytherapy (HR 0.82, 95%CI 0.74-0.93, p=0.002) were each associated with improved survival for women with stage IB. In the propensity matched cohort, RT was associated with improved survival (0.85, 95% CI 0.78-0.92, p<0.001). CONCLUSION: The use of adjuvant RT for women with stage I EC is highly dependent on stage/grade and is associated with improved survival for stage IB.

A Comparison of Outcomes Between Open Hysterectomy and Robotic-Assisted Hysterectomy for Endometrial Cancer Using the National Cancer Database.

PURPOSE: The purpose of this study is to evaluate usage patterns and outcomes of women who underwent open hysterectomy (OH) versus robotic assisted-hysterectomy (RAH) for the treatment of endometrial cancer. METHODS: Women with nonmetastatic endometrial adenocarcinoma diagnosed between 2010 and 2012, who either underwent an OH or RAH, were selected from the National Cancer Database. The χ, Fisher exact, or Mann-Whitney U tests were used where appropriate to compare outcomes between groups. Multivariable logistic regression was used to analyze for predictors for RAH and other outcome variables. RESULTS: A total of 43,985 women were included in this study with a median age of 61 years. Of these, 23,872 (54.3%) underwent RAH and 20,113 (45.7%) underwent OH. The usage of RAH increased from 43.0% in 2010 to 63.8% in 2012 (P < 0.001). Women receiving RAH were more commonly found to have a Charlson comorbidity score of 0 to 1, lower pathologic stage, nonblack race, treatment at a comprehensive center, and had insurance other than Medicaid. Robotic-assisted hysterectomy was associated with a shorter inpatient stay, lower readmission rates, and lower 30- and 90-day mortality rates (P < 0.001 for all comparisons). There was a significant improvement in overall survival favoring RAH, 96.1% versus 94.0%, which persisted on multivariable logistic regression (P < 0.001). CONCLUSIONS: In this large, hospital-based analysis, RAH was associated with decreased length of stay, lower readmission rates, and less perioperative mortality. However, socioeconomic status continues to remain a barrier to equal treatment allocation. Overall survival was improved with RAH, but the follow-up is limited, and this finding must be interpreted with caution.

Utilization of adjuvant therapies and their impact on survival for women with stage IIIC endometrial adenocarcinoma.

PURPOSE/OBJECTIVES: Adjuvant treatment options following surgical staging for women with stage IIIC endometrial carcinoma include chemotherapy (CT) with or without radiation therapy (RT). We utilized the National Cancer Database (NCDB) to investigate utilization of adjuvant CT and RT for this group of patients and assess their impact on overall survival (OS). MATERIALS/METHODS: The NCDB was queried for patients diagnosed with non-metastatic surgically staged uterine adenocarcinoma between 2004 and 2011 with at least one pathologically positive lymph node. Overall survival (OS) was analyzed using the Kaplan-Meier method. Comparison was made between patients receiving no additional therapy, RT alone, CT alone, or a combination of CT and RT (CMT). Multivariable cox regression analysis (MVA) was performed to evaluate the effect of covariates on OS. RESULTS: A total of 6720 patients were included in this study. Of whom, 1409 received no adjuvant treatment, 1533 received CT only, 1265 received RT only, and 2522 received CMT. The 5-year OS for patients receiving no adjuvant therapy, RT alone, CT alone, and CMT were 54.9%, 63.9%, 64.4%, and 72.6%, respectively. On pairwise analysis, CMT was associated with improved survival compared to all other subgroups (p<0.001). On MVA, CMT (HR 0.58, 95% CI 0.52-0.66, p<0.001) was the strongest predictor for improved OS compared to RT alone (HR 0.79, 95% CI 0.69-0.89, p<0.001) or CT alone (HR 0.75, 95% CI 0.66-0.85, p<0.001). CONCLUSIONS: Both adjuvant CT and adjuvant RT were associated with improved OS for women with stage IIIC endometrial adenocarcinoma, but CMT was associated with the largest improvement in OS.

The Community Preceptor Crisis: Recruiting and Retaining Community-Based Faculty to Teach Medical Students-A Shared Perspective From the Alliance for Clinical Education.

ISSUE: Community-based instruction is invaluable to medical students, as it provides "real-world" opportunities for observing and following patients over time while refining history taking, physical examination, differential diagnosis, and patient management skills. Community-based ambulatory settings can be more conducive to practicing these skills than highly specialized, academically based practice sites. The Association of American Medical Colleges and other national medical education organizations have expressed concern about recruitment and retention of preceptors to provide high-quality educational experiences in community-based practice sites. These concerns stem from constraints imposed by documentation in electronic health records; perceptions that student mentoring is burdensome resulting in decreased clinical productivity; and competition between allopathic, osteopathic, and international medical schools for finite resources for medical student experiences. EVIDENCE: In this Alliance for Clinical Education position statement, we provide a consensus summary of representatives from national medical education organizations in 8 specialties that offer clinical clerkships. We describe the current challenges in providing medical students with adequate community-based instruction and propose potential solutions. IMPLICATIONS: Our recommendations are designed to assist clerkship directors and medical school leaders overcome current challenges and ensure high-quality, community-based clinical learning opportunities for all students. They include suggesting ways to orient community clinic sites for students, explaining how students can add value to the preceptor's practice, focusing on educator skills development, recognizing preceptors who excel in their role as educators, and suggesting forms of compensation.

Pearls and pitfalls in letters of recommendation for neurology residency applications.

Letters of recommendation are a cornerstone of residency applications. Variability and bias in letters exists across specialties, neurology being no exception. Studies done in other specialty fields assessing nuanced language uncovered key attention points for improvement and mitigation of bias, lessons from which should be applied in the field of neurology. We review common pearls and pitfalls in the letter solicitation, writing and reading process, with suggested best-practices for residency applicants, letter writers, and program faculty reviewers. We advocate for the thoughtful selection of writers, emphasis on highlighting professional skills, and attention to implicit bias. This discussion focuses on recommendations for US advanced or categorical neurology programs, but elements of this guidance may apply more broadly to fellowship and faculty promotion letters as well.

Bringing a Structural Competency Framework to the (Simulated) Bedside: The Premature Discharge Objective Structured Clinical Exam.

PROBLEM: Structural competency is increasingly valued as a framework to address health equity within undergraduate medical education. As of academic year 2023-2024, the Liaison Committee on Medical Education (LCME) requires that medical schools have content regarding basic principles of structurally competent health care. Despite encouraging data about the effectiveness of structural competency curricula, most occur within the walls of a classroom and do not enter the authentic or simulated clinical space. APPROACH: From 2022 to 2023, an objective structured clinical exam (OSCE) focused on premature discharge, previously known as discharge against medical advice, was integrated into the required fourth-year Health Policy course at Weill Cornell Medical College, which uses the framework of structural competency. After a simulated clinical encounter, students completed a reflection assignment and participated in group debriefing to reflect on how policy coursework affected their simulated clinical experience. Students completed an evaluation about their OSCE experience, and OSCE checklist performance was analyzed. OUTCOMES: Of 82 students who participated in the curriculum, 68 completed a curricular evaluation, and 62 consented to have their OSCE performance evaluated for research. Mean overall OSCE checklist performance evaluating students' patient-centered communication skills, harm reduction skills, and discharge planning and counseling was 14.3/16 (89.6%; standard deviation 9.8%). Students reported it was valuable to focus on structural factors affecting care within the simulated clinical encounter by using the structural competency framework. NEXT STEPS: To the authors' knowledge, this is the first OSCE for medical students designed to deepen their understanding of structural competency by embedding the experience into an existing course using the framework. Future work should explore how this curriculum affects students' attitudes toward structurally vulnerable patients. With structural competency as an LCME requirement, the use of OSCEs may give educators a means to teach and assess fundamental concepts.

An Objective Structured Clinical Exam on Breaking Bad News for Clerkship Students: In-Person Versus Remote Standardized Patient Approach.

Introduction: Telemedicine training for medical students is critical as that modality becomes integral to patient care. This formative standardized patient (SP) objective structured clinical exam (OSCE) lets students discuss miscarriage diagnosis and treatment virtually. Methods: The SP OSCE was a mandatory session during the obstetrics and gynecology clerkship. Students received immediate feedback and optional individual reviews with clerkship directors. Students completed a nonmandatory survey at the end to describe their experience. SPIKES protocol student responses (i.e., proportion of correct responses) from in-person and remote SP versions were compared. Results: Between July 2019 and March 2020, 79 students completed the in-person OSCE. Between July 2020 and June 2021, 149 students completed the remote SP encounter OSCE. Students who participated in the remote versus the in-person OSCE were more likely to admit their lack of knowledge when not equipped (p = .02), be seated during the encounter (p = .03), show listening body language (p = .13), assess the SP's perception (p = .19) and understanding (p = .20), and correct the SP's misunderstandings (p = .14). Of 84 students from eight rotations, including both in-person and remote formats, 99% believed learning objectives were clear, 91% felt preparation material was adequate, 95% thought the instructor summarized important points, 97% learned something in caring for gynecological patients, and 96% perceived the OSCE to be a worthwhile educational experience. Discussion: The remote OSCE was well received by students. Breaking bad news virtually met assessment goals. Telemedicine training should be incorporated into medical school curricula.

A national survey of Neurology Vice Chairs For Education.

OBJECTIVES: A growing number of Neurology Departments have appointed a Neurology Vice Chair for Education (NVCE), yet the roles and responsibilities of an NVCE have not been previously described in the literature. METHODS: A group of current NVCEs developed a survey that was sent to all NVCEs in the US via a secure, anonymous survey. Questions included roles and responsibilities, sources of support, metrics to determine success, faculty development, basic demographics and education scholarship engagement. RESULTS: Response rate was 27 of 45 NVCEs (60%). Among the respondents, 70% have been in the role 5 years or less and the NVCE role existed for 5 years or less in 60% of departments. Eighteen percent were provided with a written job description, and 63% never received any job description. Most common responsibilities included overseeing student (78%), resident (78%), and fellowship (74%) education, participation in education section of an annual report (67%) and oversight of education scholarship (59%). Fifty-two percent reported no specific funding for the NVCE role. Most were prior program directors (59%), male (61%) and White (85%). CONCLUSIONS: The NVCE role is new, and few have written job descriptions or specific funding for the role. They oversee education across the continuum of learners in their departments, communicate the education mission in an annual report and oversee educational scholarship. Most were not formally trained for the role and previously served in other education leadership roles. These data will be useful to programs in creating job descriptions and goals for the NVCE role.

The development of a diversity, equity, and inclusion committee in a neurology department and residency program.

BACKGROUND: Diversity, Equity, and Inclusion (DEI) initiatives have been described in different academic and graduate medical education settings, but not specifically in neurology. OBJECTIVE: To describe the development of a DEI committee within a neurology department and training program. METHODS: The need to prioritize DEI as a critical focus within our neurology department led to the appointment of an initial task force who identified strategic priorities and stakeholders to establish a committee. DEI committee members included faculty, trainees, and staff, and this phase of the initiative took place from May 2019 through January 2021. RESULTS: The DEI committee was established and has met monthly for over one year. Initial meetings formulated goals of the initiative. Specific objectives were developed in the domains of recruitment, education, engagement, training, conflict resolution, and recognition. Early outcomes included augmented resident recruitment efforts of UiM students, curriculum changes including frequent representation of DEI topics in Grand Rounds, and measures to reduce unconscious bias. CONCLUSIONS: The creation of a DEI Committee within a specialty department such as neurology is feasible and can result in immediate and long-term actions related to recruitment and education in particular. Our blueprint that heavily involves graduate medical education stakeholders may be generalizable to other specialty departments in academic medicine.

Emerging Subspecialties in Neurology: Becoming an Editor-In-Chief.

An Editor-in-Chief leads the editorial team and supervises the daily tasks required to prepare articles for publication while managing the overall content and style of the journal. To become Editor-in-Chief, one must have dedicated work ethic, close attention to detail, passion for the editorial process, and a keen ability to work with and give feedback to section editors and authors. For this article, we interviewed Dr. Steven L. Lewis, Dr. Joseph E. Safdieh, and Dr. S. Andrew Josephson about their collective experience of becoming Editors-in-Chief of Continuum, Neurology Today, and JAMA Neurology, respectively. We have compiled tips for aspiring medical writers and editors, based on their expert advice, to guide trainees in this potential career path.

Curricular response to COVID-19: real-time interactive telehealth experience (RITE) program.

Introduction. The COVID-19 pandemic placed an unprecedented strain on academic healthcare systems necessitating a pause in medical student teaching in clinical care settings, including at Weill Cornell Medicine (WCM). WCM had a preexisting telemedicine curriculum, but limited opportunities for students to apply knowledge and skills related to direct virtual patient care. The authors describe the rapid implementation of real-time interactive telehealth experience (RITE) courses for clerkship students to allow for meaningful engagement in remote patient care and continuation of academic progress during the pause.Methods of Course Development. Medical school administration disseminated a request for proposals for RITE courses conforming to the WCM electives format with rapid turnaround time of 1 week or less. Requirements included remote care activities, goals and objectives, general logistics, supervision methods and standards of achievement. RITE courses were developed in outpatient medicine, inpatient medicine, psychiatry and women's health. A lottery process was developed to register students for the approved courses.Course Implementation and Evaluation. Using the technical platform and standard course registration process, students were assigned to 74 of 76 available RITE course slots. Students participated in supervised remote direct patient care and also provided critical support for frontline healthcare workers by performing remote clinical tasks. Online teaching and reflection sessions were incorporated into each RITE curricular offering. Student feedback was overall positive ranging from 3.33-4.57 out of 5.Discussion. The COVID-19 pandemic created a need to rapidly incorporate telehealth models in order to continue to deliver patient care and an opportunity to develop innovative remote educational experiences. We developed a framework for structured real-time interactive telehealth experiences to address COVID-19 related curricular needs that will be continued post-COVID-19. This expanded telehealth curriculum for our students will provide standardized training in telehealth logistics, communication techniques, and care delivery now essential for graduating medical students.

Transitioning preclinical students into clerkships amidst curricular disruptions from the COVID-19 pandemic.

The COVID-19 pandemic resulted in significant disruptions to medical education. The patient care space was unavailable as a learning environment, which compounded the complexity of preparing students for clerkships with a traditional transition to clerkship (TTC) curriculum. We developed a multimodal, structured approach to re-introduce students to the clinical space prior to the start of clerkships. 105 second year medical students completed a 4-week clinical enhancement course. A modified Delphi method was used to select core topics, which were then anchored to key Entrustable Professional Activities (EPAs). Students participated in 9 virtual problem-based cases, workshops and multiple supervised patient encounters. Students were surveyed before, during, and after the course; responses were compared with paired t-tests. 25.9% rated the course as excellent, 44.2% as very good, and 19.5% as good. Compared to baseline, self-perceived efficacy grew significantly (P < 0.05) across all EPAs. Improvements in key competencies were sustained when students were surveyed 2 weeks into their first clerkship. This was a well-received, novel course, focused on helping students transition back into the clinical space through a multimodal teaching approach. This framework may be used by other institutions seeking to restructure their TTC initiatives.

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.

A proposal for a coordinated effort for the determination of brainwide neuroanatomical connectivity in model organisms at a mesoscopic scale.

In this era of complete genomes, our knowledge of neuroanatomical circuitry remains surprisingly sparse. Such knowledge is critical, however, for both basic and clinical research into brain function. Here we advocate for a concerted effort to fill this gap, through systematic, experimental mapping of neural circuits at a mesoscopic scale of resolution suitable for comprehensive, brainwide coverage, using injections of tracers or viral vectors. We detail the scientific and medical rationale and briefly review existing knowledge and experimental techniques. We define a set of desiderata, including brainwide coverage; validated and extensible experimental techniques suitable for standardization and automation; centralized, open-access data repository; compatibility with existing resources; and tractability with current informatics technology. We discuss a hypothetical but tractable plan for mouse, additional efforts for the macaque, and technique development for human. We estimate that the mouse connectivity project could be completed within five years with a comparatively modest budget.