ARTICLE IN BRIEF:
The traditional goals of a neurology residency remain the same—to provide apprentice training at the bedside. But the training focus and models have changed. Four neurology residency program directors highlight what's new and what remains the same.
When Zachary London, MD, started his neurology residency at the University of Michigan in 2005, the program focused mostly on lectures. Although there were online components, the hospital was just moving from written medical records to an electronic format.
Forward a decade and change. Dr. London, who is now the residency director and clinical associate professor of neurology at the University of Michigan, has introduced more interactive workshops, educational modules about teaching, self-directed online learning activities, and wellness practices for the 27 residents (seven of whom are in neurology, two in pediatric neurology).
But new ways of teaching do not mean that residency programs have forgotten their core values, he said.
“The fundamental aspects of residency have not changed—it's still an apprentice learning at the bedside. That's still the best teacher, and I'm a firm believer in that system,” said Dr. London. “There's no way we're replacing residency with textbooks or e-learning modules only. It's still about the patients.”
Neurology residency programs have long involved didactic lectures and memorization. But now residency directors are including more time on social interaction, group work, and “flipping the classroom” practices in which residents present the material in a more interactive and engaged manner than the older models of passive listening.
Neurology Today talked to four residency directors about new initiatives in their programs and what lies ahead.
University of Connecticut
“With the current generation of learners, many medical schools have ‘flipped the classroom,’ where they've gotten rid of the big lectures and now everything is interactive and discussion-based,” said Erica A. Schuyler, MD, neurology residency program director for the University of Connecticut and associate chief of education for neurology at Hartford Hospital. “These are students who have always had technology at their fingertips and it's such an important part of how they learn. It's important for us to change our style, but it's hard to change all of our lecture formats overnight; it's been more of a gradual process.”
“We've started taking more advantage of our simulation center, where residents can practice procedural lumbar punctures and we can run mock stroke codes, or teach coma exams, or how to determine brain death,” Dr. Schuyler said. “It's a specific clinical teaching approach where we can give feedback.”
It's important that the faculty are interested in developing educational tools, she said, and share different ways of teaching the material. For example, to enhance the quality of patient interaction and communication, the program incorporated a simulated family meeting (with actors). “We're working on a section about palliative care, and developing cases where residents need to communicate bad news, or goals of care, or end-of-life care,” she said. “It gives us a chance to do an observed structured clinical exam, where we videotape them, and the patients rate them and we give them feedback.”
Over time, Dr. Schuyler said, the program has been trying to make their grand rounds more interactive. Some of the speakers use an audience response system — they use their cell phone to respond to questions or a multiple choice option. And speakers are using fewer slides, incorporating more of a TED-talk style, rather than standing at the podium and reading notes from slides. Those are the talks that are more interesting and well received, she said. But, she added, “We can't forget that while we're changing the way we teach, we still need to watch our outcomes and make sure we're effectively teaching the material.”
Emory School of Medicine
“We have a lot of innovative education practices to reach the residents, and one of the things we've started in this academic year is an EEG longitudinal course,” said Rebecca E. Fasano, MD, program director of the neurology residency training program at Emory University School of Medicine and assistant professor of neurology in the epilepsy section.
“Our residents do a one-month rotation in EEG during the PGY2 year and one month during the PGY3 year; we noticed that their EEG reading skills became rusty in between those rotations,” Dr. Fasano explained. To keep their skills fresh, the program started a monthly EEG longitudinal course during resident didactics. During the course, the residents break up into three groups and review different “unknown” EEGs selected by the fellow. The group that gets the most EEGs “correct” wins a prize. “It's fun for the residents and a great way to keep them engaged,” she said.
Dr. Fasano said the program also started doing a weekly neurosigns session in which a resident reviews an exam finding with the group, for example, the Hoffman sign. The resident explains the physical finding, including its pathophysiology, and often shows a video to the rest of the group.
And starting this month, the program is starting a lecture series on topics pertinent to academic medicine: for example, how to run a clinical trial, how to apply for grant funding, how to give a research talk, how to build a CV.
“We're also trying to include more didactics lectures on the business aspects of medicine, quality improvement, and health care disparities,” Dr. Fasano said.
“At the end of the year, I talk to the residents to see what lectures they enjoyed and what they want more of,” she continued. “Last year they wanted more anatomy, so we brought in the anatomy faculty from Emory University to give more anatomy lectures. I also look at the in-service exams and see where the deficiencies are and where we need to bulk up in terms of lectures for next year.”
Warren Albert Medical School
“Our program is fairly traditional,” said Jonathan F. Cahill, MD, assistant professor of neurology and director of the neurology residency program at the Warren Alpert Medical School at Brown University. “Every month we choose a topic—one month it might be epilepsy, another month it might be multiple sclerosis, and we have two academic conferences each day. The morning case might be a discussion about something that happened overnight, or a particularly interesting case that happened, and the noon [case] is a didactic lecture led by the faculty.”
“In the four years I've been director of the program, I've found that some of the (Accreditation Council for Graduate Medical Education) milestones are really hard to assess,” Dr. Cahill continued. “For example, [a milestone might be that] residents need to be assessed on low frequency events such as movement disorders emergencies. In our mock oral board sessions, we have six faculty members work through cases with the six residents. The cases for one session might be quite varied: a movement disorders emergency, a neuro-oncology case, a multiple sclerosis case, or a migraine with aura, for example.”
Dr. Cahill said the program also includes journal clubs that they try to incorporate into the monthly didactic lecture. “We'll ask a resident to analyze a study alongside a faculty member. I'm an MS doctor, so the resident assigned to the journal with me that month will pick relevant articles, let's say, on the use of ocrelizumab, and the resident will read and present the articles over a half hour. Then I take on the part of analyzing the statistics and open it up for discussion. How might these studies impact your clinical practice? How are they relevant to patient care? What are the strengths and limitations?”
Dr. Cahill acknowledged that in medical education, there has been an emphasis on “flipping the classroom” and having residents prepare before conferences, but, he said, they have full-time jobs and work many hours. “Doing a lot of extra readings is hard for them,” he said. “And it doesn't always work.”
“Neuroanatomy is a hard topic to teach in a lecture, so we'll go through a neuroanatomy textbook and one resident leads the discussion for a particular chapter,” he said. “Then I've created a series of quizzes to go along with that chapter to keep them interested and engaged, and maybe there's a coffee gift card to the person with the highest total.”
“For the first two years, the training program still relies on lectures,” he said, “but the school has created two elective tracks–clinician educator and global health—outside the residency curriculum for PGY3-PGY4 residents, and are made up of educational workshops, lectures, conferences, and the completion of a scholarly project. When completed, they get a certificate saying they've completed those tracks.”
University of Michigan
In our program we focus on “just-in-time” learning versus “just-in-case learning,” said Dr. London, residency director at the University of Michigan. “That means I'm teaching you something without a patient physically in front of you—there may be a lecture on amyotrophic lateral sclerosis (ALS) just in case you have a patient and hope that you harken back to this lecture and remember what we've talked about.”
In a “just-in-time approach,” Dr. London said, you may have a patient with ALS and need to research that now and talk to people and go to online resources and know what to look for. “It's far more active for residents, and you have online resources and the people resources right there,” he said. “There are gaps in teaching about these rare diseases and areas like pathophysiology and basic science, but we can fill those in with more didactic lectures.”
The program also includes a one-month non-clinical boot camp rotation that all of the residents do the last month of their PGY1 year, before starting neurology. “That's where we use a lot of case discussions, teaching workshops, and simulations to go over lumbar punctures, stroke and epilepsy mock codes—having all these people together at a time when their schedule is more free smooths the transition into the academic year, which starts in July,” he said.
Dr. London also described a program he calls the “daily constitutional.”
“I took it from my wife's grandmother who would always say that she couldn't go out before her “daily constitutional,” which was a walk with her ladies at 10 AM. “We might have a guided tour through the park, or a yoga class, or meditation. It's not required, but most residents come. There are a few high-intensity interval training workouts that might not work for everyone, but generally we all like the idea of not being trapped in the hospital all day.”
One other thing the program has included is the “EMG whiz”–http://www.emgwhiz.com—a web-based tool that allows people to learn electromyography and nerve conduction studies. It's aimed at residents and neuromuscular fellows. “It presents a case with a little information and you have to choose what nerves and muscles you're going to test, and then, based on the results, you decide what you're going to do next,” Dr. London said. “It gives you feedback, whether you did enough tests to prove the diagnosis or rule out one, it truly is interactive in a way we could not do with a textbook.”
On Residency Training: A Recent Graduate's View
Jennifer Vermilion, MD, graduated from the pediatric neurology program at the University of Rochester and is now a fellow in Rochester's Experimental Therapeutics and Pediatric Movement Disorders program.
“There's been an ongoing journal club as long as I've been in the program,” she said. “It meets a couple times a quarter, and it's usually at an attending's house. They'll have food and drinks and we all hang out—it makes it more of a social event and encourages people to come out.”
“We also have noon conferences, that are mostly reserved for general neurology discussions, but every few months we have a different topic,” she continued. “We had one on coding for residents and junior faculty, how do you code procedures, for example. And we had a lawyer come and explain how to go over a contract.
“There's a bit more of a push to discuss the business end of medicine. I know in the fellowship world, we've had a lot of workshops about different aspects of being a doctor, and there definitely needs to be more of that,” she said.