Subacute combined degeneration of the spinal cord in a patient with nitrous oxide use and autoimmune atrophic gastritis.

Nitrous oxide is among the most common drugs used by adolescents and young adults, and its neuropsychiatric sequelae are severe but reversible with timely treatment. The causal mechanism relates to impaired metabolism of vitamin B12, which is necessary for the development and maintenance of the myelin sheath. Individuals most susceptible to neuropsychiatric manifestations are those with a secondary cause of vitamin B12 deficiency, including nutritional deficiency and impaired absorption, or an alternative cause of impaired metaboclism. We describe the case of a man in his thirties who developed subacute combined degeneration of the spinal cord and polyneuropathy in the setting of recreational nitrous oxide use and autoimmune atrophic gastritis. Our case highlights clinical pearls for diagnosis and treatment, differential diagnosis, common concomitant aetiologies and the importance of screening for substance use disorder and psychiatric comorbidities.

How do smoking, vaping, and nicotine affect people with epilepsy and seizures? A scoping review protocol.

BACKGROUND: Epilepsy is a prevalent disease that requires personalized care to control seizures, reduce side effects, and ameliorate the burden of comorbidities. Smoking is a major cause of preventable death and disease. There is evidence that patients with epilepsy smoke at high rates and that smoking may increase seizure frequency. However, there is a lack systematically synthesized evidence on the interactions between epilepsy and seizures and smoking, tobacco use, vaping, and smoking cessation. METHODS AND ANALYSIS: This scoping review protocol guided by the Joanna Briggs Institute Manual for Evidence Synthesis and the PRISMA Extension for Scoping Reviews will investigate what is known about the interactions between smoking and epilepsy. This review will include the population of persons with all types of epilepsy or seizures and examine an inclusive list of concepts including tobacco use, vaping, nicotine replacement, and smoking cessation. The MEDLINE, Embase, APA Psycinfo, CINAHL, Cochrane, Scopus, and Web of Science databases will be searched. Following systematic screening of records, data will be charted, synthesized, and summarized for presentation and publication. ETHICS AND DISSEMINATION: No ethical approval is required for this literature-based study. The results of this scoping review will be submitted for publication in a peer-reviewed journal. This synthesis will be informative to clinicians and direct further research that may improve health outcomes for people with epilepsy. REGISTRATION: This protocol is registered with the Open Science Framework (DOI: https://doi.org/10.17605/OSF.IO/D3ZK8).

Comparing Entrustment Decision-Making Outcomes of the Core Entrustable Professional Activities Pilot, 2019-2020.

Importance: Gaps in readiness for indirect supervision have been identified for essential responsibilities encountered early in residency, presenting risks to patient safety. Core Entrustable Professional Activities (EPAs) for entering residency have been proposed as a framework to address these gaps and strengthen the transition from medical school to residency. Objective: To assess progress in developing an entrustment process in the Core EPAs framework. Design, Setting, and Participants: In this quality improvement study in the Core EPAs for Entering Residency Pilot, trained faculty made theoretical entrustment determinations and recorded the number of workplace-based assessments (WBAs) available for each determination in 2019 and 2020. Four participating schools attempted entrustment decision-making for all graduating students or a randomly selected subset of students. Deidentified, individual-level data were merged into a multischool database. Interventions: Schools implemented EPA-related curriculum, WBAs, and faculty development; developed systems to compile and display data; and convened groups to make theoretical summative entrustment determinations. Main Outcomes and Measures: On an EPA-specific basis, the percentage of students for whom an entrustment determination could be made, the percentage of students ready for indirect supervision, and the volume of WBAs available were recorded. Results: Four participating schools made 4525 EPA-specific readiness determinations (2296 determinations in 2019 and 2229 determinations in 2020) for 732 graduating students (349 students in 2019 and 383 students in 2020). Across all EPAs, the proportion of determinations of "ready for indirect supervision" increased from 2019 to 2020 (997 determinations [43.4%] vs 1340 determinations [60.1%]; 16.7 percentage point increase; 95% CI, 13.8-19.6 percentage points; P < .001), as did the proportion of determinations for which there were 4 or more WBAs (456 of 2295 determinations with WBA data [19.9%] vs 938 [42.1%]; 22.2 percentage point increase; 95% CI, 19.6-24.8 percentage points; P < .001). The proportion of EPA-specific data sets considered for which an entrustment determination could be made increased from 1731 determinations (75.4%) in 2019 to 2010 determinations (90.2%) in 2020 (14.8 percentage point increase; 95% CI, 12.6-16.9 percentage points; P < .001). On an EPA-specific basis, there were 5 EPAs (EPA 4 [orders], EPA 8 [handovers], EPA 10 [urgent care], EPA 11 [informed consent], and EPA 13 [patient safety]) for which few students were deemed ready for indirect supervision and for which there were few WBAs available per student in either year. For example, for EPA 13, 0 of 125 students were deemed ready in 2019 and 0 of 127 students were deemed ready in 2020, while 0 determinations in either year included 4 or more WBAs. Conclusions and Relevance: These findings suggest that there was progress in WBA data collected, the extent to which entrustment determinations could be made, and proportions of entrustment determinations reported as ready for indirect supervision. However, important gaps remained, particularly for a subset of Core EPAs.

Entrustment Decision Making in the Core Entrustable Professional Activities: Results of a Multi-Institutional Study.

PURPOSE: In 2014, the Association of American Medical Colleges defined 13 Core Entrustable Professional Activities (EPAs) that all graduating students should be ready to do with indirect supervision upon entering residency and commissioned a 10-school, 5-year pilot to test implementing the Core EPAs framework. In 2019, pilot schools convened trained entrustment groups (TEGs) to review assessment data and render theoretical summative entrustment decisions for class of 2019 graduates. Results were examined to determine the extent to which entrustment decisions could be made and the nature of these decisions. METHOD: For each EPA considered (4-13 per student), TEGs recorded an entrustment determination (ready, progressing but not yet ready, evidence against student progressing, could not make a decision); confidence in that determination (none, low, moderate, high); and the number of workplace-based assessments (WBAs) considered (0->15) per determination. These individual student-level data were de-identified and merged into a multischool database; chi-square analysis tested the significance of associations between variables. RESULTS: The 2,415 EPA-specific determinations (for 349 students by 4 participating schools) resulted in a decision of ready (n = 997/2,415; 41.3%), progressing but not yet ready (n = 558/2,415; 23.1%), or evidence against student progression (n = 175/2,415; 7.2%). No decision could be made for the remaining 28.4% (685/2,415), generally for lack of data. Entrustment determinations' distribution varied across EPAs (chi-square P < .001) and, for 10/13 EPAs, WBA availability was associated with making (vs not making) entrustment decisions (each chi-square P < .05). CONCLUSIONS: TEGs were able to make many decisions about readiness for indirect supervision; yet less than half of determinations resulted in a decision of readiness to perform this EPA with indirect supervision. More work is needed at the 10 schools to enable authentic summative entrustment in the Core EPAs framework.

Multi-Residency Implementation of an Online Movement Disorders Curriculum Based on Real Patient Videos.

Background: In-person didactic education in residency has numerous challenges including inconsistent availability of faculty and residents, limited engagement potential, and non-congruity with clinical exposure. Methods: An online curriculum in movement disorders was implemented across nine neurology residency programs (six intervention, three control), with the objective to determine feasibility, acceptability, and knowledge growth from the curriculum. Residents in the intervention group completed ten modules and a survey. All groups completed pre-, immediate post-, and delayed post-tests. Results: Eighty-six of 138 eligible housestaff (62.3%) in the intervention group completed some modules and 74 completed at least half of modules. Seventy-four, 49, and 30 residents completed the pre-, immediate post-, and delayed post-tests respectively. Twenty-five of 42 eligible control residents (59.5%) completed at least one test. Mean pre-test scores were not significantly different between groups (6.33 vs. 6.92, p = 0.18); the intervention group had significantly higher scores on immediate post- (8.00 vs. 6.79, p = 0.001) and delayed post-tests (7.92 vs. 6.92, p = 0.01). Residents liked having a framework for movement disorders, appreciated the interactivity, and wanted more modules. Residents completed the curriculum over variable periods of time (1-174 days), and at different times of day. Discussion: This curriculum was feasible to implement across multiple residency programs. Intervention group residents showed sustained knowledge benefit after participating, and residents took advantage of its flexibility in their patterns of module completion. Similar curricula may help to standardize certain types of clinical learning and exposure across residency programs. Highlights: Interactive online tools for resident didactic learning are valuable to residents. Residents learn from interactive online curricula, find the format engaging, and take advantage of the flexibility of online educational tools. Beginner learners appreciate algorithms that help them to approach a new topic.

Optimizing preclinical learning with retrieval practice: A call to action.

This Personal View is about our experience with preclinical education as medical students. We discuss the problem with current medical education in light of an ever-growing body of medical knowledge and increasing student disengagement with preclinical lectures. We briefly review the concept of retrieval practice as an effective, evidence-based learning strategy that helped us retain knowledge for longer periods and propose that medical educators should adopt this strategy to best prepare medical students to navigate the vastly expanding scope of modern medicine.

An online curriculum in movement disorders for neurology housestaff.

INTRODUCTION: In 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. METHODS: We 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. RESULTS: The 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. CONCLUSION: We 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.

Developing an Entrustment Process: Insights from the AAMC CoreEPA Pilot.

One of the main goals of the CoreEPA pilot has been to determine the feasibility of developing a process to make summative entrustment decisions regarding entrustable professional activities (EPAs). Five years into the pilot, we report results of a research study we conducted to explore approaches to the entrustment process undertaken by our ten participating schools. We sought to identify the choices that participating schools made regarding the entrustment process and why these decisions were made. We are sharing these results, highlighting ongoing challenges that were identified with the intent of helping other medical schools that are moving toward EPA-based assessment. We conducted semi-structured interviews with representatives of all 10 medical schools in the CoreEPA pilot to understand their choices in designing the entrustment process. Additional information was obtained through follow-up communication to ensure completeness and accuracy of the findings. Several common themes are described. Our results indicate that, while approaches to the entrustment process vary considerably, all schools demonstrated consistent adherence to the guiding principles of the pilot. Several common barriers to the entrustment process emerged, and there was a consensus that more experience is needed with the process before consequential entrustment decisions can be made. The CoreEPA pilot schools continue to address challenges identified in implementing entrustment processes and making entrustment decisions for our students graduating in the Class of 2020.

Epilepsy Education: Recent Advances and Future Directions.

PURPOSE OF REVIEW: The goal of this review is to survey the current literature on education in epilepsy and provide the most up-to-date information for physicians involved in the training of future doctors on this topic. We intended to review what opportunities exist to enhance our current teaching practices that may not be well-known or widely used, but may be adapted to a broader audience. RECENT FINDINGS: Many new techniques adopting principles of education (e.g., retrieval practice and spaced learning) or new technologies (e.g., pre-recorded lectures, computer-enhanced modules, and simulation practice) have been trialled to enhance medical education in epilepsy with some success. Many of these techniques are currently adaptable to a wider audience or may soon be available. The use of these opportunities more broadly may allow expansion of educational research opportunities as well as enhancing our ability to pass on information. As the knowledge base in epilepsy continues to dramatically expand, we need to keep evaluating our teaching techniques to ensure we are able to pass along this knowledge to our future providers.

The Future of the Lecture in Neurology Education.

The lecture has been a core pedagogical method since the early days of formal medical education. Although approaches to formal lectures have evolved over the years, there has been ongoing debate about the role that lectures should play in modern medical education. Arguably, traditional lectures do not align well with modern learning theory, and do not take full advantage of our current knowledge of how people learn. In many modern medical curricula, lectures have been replaced by self-study activities, including video-based lectures, computer-based learning modules, and other self-directed learning. We argue that scheduled "together time" is still important, particularly in neurology education, where there is a strong emphasis on clinical reasoning. We outline alternative teaching methods that effectively use this time, including the flipped classroom, just-in-time teaching, problem-based learning, and team-based learning. We discuss ways in which these approaches may be particularly conducive to components of neurology education.

Test-enhanced learning in health professions education: A systematic review: BEME Guide No. 48.

BACKGROUND: Cognitive psychology studies demonstrate that subjects who attempt to recall information show better learning, retention, and transfer than subjects who spend the same time studying the same material (test-enhanced learning, TEL). We systematically reviewed TEL interventions in health professions education. METHODS: We searched 13 databases, 14 medical education journals, and reference lists. Inclusion criteria included controlled studies of TEL that compared TEL to studying the same material or to a different TEL strategy. Two raters screened articles for inclusion, abstracted information, determined quality scores, and calculated the standardized mean difference (SMD) for the learning outcomes. RESULTS: Inter-rater agreement was excellent for all comparisons. The 19 included studies reported 41 outcomes with data sufficient to determine a SMD. TEL interventions included short answer questions, multiple choice questions, simulation, and standardized patients. Five of six immediate learning outcomes (SMD 0.09-0.44), 21 of 23 retention outcomes (SMD 0.12-2.5), and all seven transfer outcomes (SMD 0.33-1.1) favored TEL over studying. CONCLUSIONS: TEL demonstrates robust effects across health professions, learners, TEL formats, and learning outcomes. The effectiveness of TEL extends beyond knowledge assessed by examinations to clinical applications. Educators should include TEL in health professions curricula to enhance recall, retention, and transfer.

Insights into teaching a complex skill: Threshold concepts and troublesome knowledge in electroencephalography (EEG).

BACKGROUND: Threshold concepts (TCs) are defined as ideas within a discipline that are often conceptually difficult ("troublesome"), but when learned, transform a learner's understanding. Electroencephalography (EEG) has been recognized as a conceptually difficult field in neurology, and a study of threshold concepts in EEG may provide insights into how it is taught and learned. METHODS: Semi-structured interviews were performed with 12 EEG experts in the US and Canada. Experts identified potential TCs and troublesome knowledge, and explored how these concepts were taught and learned. Interview transcripts were coded and analyzed using a general thematic analysis approach, based on the core elements of the threshold concepts framework. RESULTS: One concept (polarity) emerged most clearly as a threshold concept. Other troublesome areas included pattern interpretation and clinical significance, but these lacked some of the characteristics of TCs. Several themes emerged, including the role of TCs and troublesome knowledge in determining expertise and the role of prior experience. CONCLUSIONS: We have used the threshold concepts framework to explore potential barriers to learning, suggest ways to support learners, and identify potential points of emphasis for teaching and learning EEG. A similar approach could be applied to the study of teaching and learning in other conceptually difficult areas of medical education.

Using learning analytics to evaluate a video-based lecture series.

BACKGROUND: The video-based lecture (VBL), an important component of the flipped classroom (FC) and massive open online course (MOOC) approaches to medical education, has primarily been evaluated through direct learner feedback. Evaluation may be enhanced through learner analytics (LA) - analysis of quantitative audience usage data generated by video-sharing platforms. METHODS AND RESULTS: We applied LA to an experimental series of ten VBLs on electroencephalography (EEG) interpretation, uploaded to YouTube in the model of a publicly accessible MOOC. Trends in view count; total percentage of video viewed and audience retention (AR) (percentage of viewers watching at a time point compared to the initial total) were examined. The pattern of average AR decline was characterized using regression analysis, revealing a uniform linear decline in viewership for each video, with no evidence of an optimal VBL length. Segments with transient increases in AR corresponded to those focused on core concepts, indicative of content requiring more detailed evaluation. We propose a model for applying LA at four levels: global, series, video, and feedback. DISCUSSION AND CONCLUSIONS: LA may be a useful tool in evaluating a VBL series. Our proposed model combines analytics data and learner self-report for comprehensive evaluation.

A Neurology Clerkship Curriculum Using Video-Based Lectures and Just-in-Time Teaching (JiTT).

Introduction: Just-in-time teaching is an educational strategy that involves tailoring in-session learning activities based on student performance in presession assessments. We implemented this strategy in a third-year neurology clerkship. Methods: Linked to core neurology clerkship lectures, eight brief video-based lectures and knowledge assessments were developed. Students watched videos and completed multiple-choice questions, and results were provided to faculty, who were given the opportunity to adjust the in-person lecture accordingly. Feedback was obtained by surveys of students and faculty lecturers and from student focus groups and faculty. Student performance on the end-of-clerkship examination was analyzed. Results: Between October 2016 and April 2017, 135 students participated in the curriculum, and 56 students (41.5%) responded to the surveys. Most students agreed or strongly agreed that the new curriculum enhanced their learning and promoted their sense of responsibility in learning the content. Faculty agreed that this pedagogy helped prepare students for class. Most students watched the entire video-based lecture, although there was a trend toward decreased audience retention with longer lectures. There were no significant changes in performance on the end-of-clerkship examination after implementation of just-in-time teaching. In focus groups, students emphasized the importance of tying just-in-time teaching activities to the lecture and providing video-based lectures well in advance of the lectures. Discussion: Just-in-time teaching using video-based lectures is an acceptable and feasible method to augment learning during a neurology clinical clerkship. We believe this method could be used in other neurology clerkships with similar success.

House staff communication training and patient experience scores.

OBJECTIVE: To assess whether communication training for housestaff via role-playing exercises (1) is well-received and (2) improves patient experience scores in housestaff clinics. METHODS: We conducted a pre-post study in which the housestaff for 3 adult hospital departments participated in communication trainingled by trained faculty in small groups . Sessions centered on a published 5-step strategy for opening patient-centered interviews using department-specific role-playing exercises. Housestaff completed post-training questionnaires. For one month prior to and one month following the training, patients in the housestaff clinics completed surveys with CG-CAHPS questions regarding physician communication, immediately following clinic visits. Pre-and post -intervention results for top-box scores were compared. RESULTS: Forty -four of a possible 45 housestaff (97.8%) participated, with 31 (70.5%) indicating that the role-playing exercise increased their perception of the 5-step strategy. No differences on patient responses to CG-CAHPS questions were seen when comparing 63 pre-intervention patients surveys to 77 post-intervention surveys. CONCLUSION: Demonstrating an improvement in standard patient experience surveys in resident clinics may require ongoing communication coaching and investigation of the "hidden curriculum" of training.