Tips for developing a coaching program in medical education

This article provides structure to developing, implementing, and evaluating a successful coaching program that effectively meets the needs of learners. We highlight the benefits of coaching in medical education and recognize that many educators desiring to build coaching programs seek resources to guide this process. We align 12 tips with Kern's Six Steps for Curriculum Development and integrate theoretical frameworks from the literature to inform the process. Our tips include defining the reasons a coaching program is needed, learning from existing programs and prior literature, conducting a needs assessment of key stakeholders, identifying and obtaining resources, developing program goals, objectives, and approach, identifying coaching tools, recruiting and training coaches, orienting learners, and evaluating program outcomes for continuous program improvement. These tips can serve as a framework for initial program development as well as iterative program improvement.

Impact of a coaching program on resident perceptions of communication confidence and feedback quality

BACKGROUND

While communication is an essential skill for providing effective medical care, it is infrequently taught or directly assessed, limiting targeted feedback and behavior change. We sought to evaluate the impact of a multi-departmental longitudinal residency communication coaching program. We hypothesized that program implementation would result in improved confidence in residents' communication skills and higher-quality faculty feedback.

METHODS

The program was implemented over a 3-year period (2019-2022) for surgery and neurology residents at a single institution. Trained faculty coaches met with assigned residents for coaching sessions. Each session included an observed clinical encounter, self-reflection, feedback, and goal setting. Eligible residents completed baseline and follow-up surveys regarding their perceptions of feedback and communication. Quantitative responses were analyzed using paired t-tests; qualitative responses were analyzed using content analysis.

RESULTS

The baseline and follow-up survey response rates were 90.0% (126/140) and 50.5% (46/91), respectively. In a paired analysis of 40 respondents, residents reported greater confidence in their ability to communicate with patients (inpatient: 3.7 vs. 4.3, p < 0.001; outpatient: 3.5 vs. 4.2, p < 0.001), self-reflect (3.3 vs. 4.3, p < 0.001), and set goals (3.6 vs. 4.3, p < 0.001), as measured on a 5-point scale. Residents also reported greater usefulness of faculty feedback (3.3 vs. 4.2, p = 0.001). The content analysis revealed helpful elements of the program, challenges, and opportunities for improvement. Receiving mentorship, among others, was indicated as a core program strength, whereas solving session coordination and scheduling issues, as well as lowering the coach-resident ratio, were suggested as some of the improvement areas.

CONCLUSIONS

These findings suggest that direct observation of communication in clinical encounters by trained faculty coaches can facilitate long-term trainee growth across multiple core competencies. Future studies should evaluate the impact on patient outcomes and workplace-based assessments.

Inpatient Neurology Deaths and Factors Associated With Discharge to Hospice

Background and Purpose

The Neurology Mortality Review Committee at our institution identified variability in location of death for patients on our inpatient neurology services. Hospice may increase the number of patients dying in their preferred locations. This study aimed to characterize patients who die on inpatient neurology services and explore barriers to discharge to hospice.

Methods

This retrospective study was completed at a single, quaternary care medical center that is a Level I Trauma Center and Comprehensive Stroke Center. Patients discharged by an inpatient neurology service between 6/2019-1/2021 were identified and electronic medical record review was performed on patients who died in the hospital and who were discharged to hospice.

Results

69 inpatient deaths and 74 discharges to hospice occurred during the study period. Of the 69 deaths, 54 occurred following withdrawal of life sustaining treatment (WLST), of which 14 had a referral to hospice placed. There were 88 "hospice-referred" patients and 40 "hospice-eligible" patients. Hospice-referred patients were less likely to require the intensive care unit than hospice-eligible patients. Hospice-referred patients had their code status changed to Do Not Intubate earlier and were more likely to have advanced directives available.

Conclusion

Our data highlight opportunities for further research to improve discharge to hospice including interhospital transfers, advanced directives, earlier goals of care discussions, palliative care consultations, and increased hospice bed availability. Importantly, it highlights the limitations of using in-hospital mortality as a quality indicator in this patient population.

A Novel Serious Illness Communication Curriculum Improves Neurology Residents' Confidence and Skills

Background and Purpose: Competency in serious illness communication is mandated by the Accreditation Council of Graduate Medical Education. Previous efforts to teach communication skills have been hampered by intensive time requirements. In this study, we developed and evaluated a brief goals-of-care communication curriculum for neurology residents. Methods: We developed and implemented a two-part curriculum based on themes identified from a needs assessment: (1) fundamental physician-patient communication skills; and (2) counseling surrogate decision makers and providing neuroprognostication. We used a three-pronged pre-post study design to evaluate the impact of the curriculum: resident self-assessment surveys, direct observations of resident-patient interactions, and patient perception surveys using the Communication Assessment Tool. Results: Residents reported a significant increase in mean scores [standard deviation] of confidence practicing fundamental communication skills, such as offering opportunities for emotion (3.84 [0.9] vs. 4.54 [0.6], p = 0.002), and goals-of-care communication skills, such as using triggers for serious conversations (2.65 [0.7] vs. 3.29 [0.5], p = 0.004). Observed resident-patient interactions showed significant improvement in fundamental communication skills, such as involving the patient in decision making (1.89 [0.6] vs. 4.0 [0.9], p < 0.001). There was no significant impact on patient perception of resident communication skills in the three months following the intervention. Conclusions: A brief, learner-centered curricular intervention improved neurology residents' confidence in serious illness communication and improved their skills as judged by trained observers.

An Electronic Health Record Intervention to Limit Viral Testing of Cerebrospinal Fluid

Meningitis and encephalitis are neurologic emergencies that require immediate management and current guidelines recommend empiric treatment with broad-spectrum antimicrobials. Cerebrospinal fluid (CSF) testing algorithms are heterogeneous and largely institution-specific, reflecting a lack of consensus on how to effectively identify CSF pathogens while conserving resources and avoiding false positives. Moreover, many lumbar punctures (LPs) performed in the inpatient setting are done for noninfectious workups, such as evaluation for leptomeningeal metastasis. As such, tailoring CSF testing to clinical context has been a focus of multiple prior reports and several healthcare systems have focused on efforts to limit low-yield diagnostic testing when a positive result is unlikely. To curb ordering viral PCRs when pre-test probability is low, some peer institutions have implemented pleocytosis criteria for virus-specific polymerase chain reaction (PCR) tests from CSF. In this report, we retrospectively analyzed the diagnostic testing of CSF from patients who had an LP while admitted to a single, large academic medical center and found that many cases of Herpes Simplex Virus (HSV) meningoencephalitis were diagnosed by non-neurologists. The rate of positive virus-specific PCR tests was very low, and tests were frequently ordered in duplicate with a multiplexed meningitis/encephalitis PCR panel (M/E panel, BioFire, Salt Lake City, UT). We designed and implemented a systems-level intervention to promote a revised stepwise testing algorithm that minimizes unnecessary tests. This intervention led to a significant reduction in the number of low-yield virus-specific PCR tests ordered without implementing a policy of cancelling virus-specific PCRs.

Physician Perceptions of Performance Feedback and Impact on Personal Well-Being: A Qualitative Exploration of Patient Satisfaction Feedback in Neurology

BACKGROUND

To understand neurologists' experiences and perspectives on patient satisfaction feedback and its impact on personal well-being and behavior.

METHODS

From May to June 2021, the researchers conducted 19 semistructured interviews with neurologists from a large academic medical center. Clinical Performance Feedback Intervention Theory informed a combined inductive and deductive thematic analysis of the qualitative data, which focused on perceptions of current feedback practices, its impact on physician behavior, and recommendations for improvement.

RESULTS

Participants tended to be female (n = 12/19, 63.2%), aged 30-39 (n = 8/19, 42.1%), white (n = 9/19, 47.4%), and were 10+ years into clinical practice (n = 18/19, 94.7%). Physicians were receptive to feedback overall, but perceptions varied by feedback type. Physicians preferred informal feedback (delivered unprompted directly by patients), given its tendency toward actionability. They disliked formal feedback (derived from anonymous surveys) due to low actionability, bias and validity issues, lack of contextual considerations, delivery through public reports, and links to financial incentives. Nearly all physicians reported formal feedback programs had the potential to negatively affect well-being and were not beneficial to their practice; a few reported adjusting their clinical practice to improve patient satisfaction performance. Five recommendations to improve patient satisfaction feedback programs emerged: Align on feedback intent, acknowledge survey limitations during program administration, increase actionability of feedback through specificity and control, support direct patient-physician feedback and problem resolution, and support empathetic integration of feedback.

CONCLUSION

Understanding physician perceptions of current approaches to patient satisfaction feedback offers the opportunity to shape subsequent collection and distribution methods to improve physician performance and optimize professional fulfillment.

Developing a multi-departmental residency communication coaching program

Background

Local needs assessments in our institution's surgery and neurology residency programs identified barriers to effective communication, such as no shared communication framework and limited feedback on nontechnical clinical skills. Residents identified faculty-led coaching as a desired educational intervention to improve communication skills. Three university departments (Surgery, Neurology, and Pediatrics) and health-care system leaders collaborated closely to develop an innovative communication coaching initiative generalizable to other residency programs.

Innovation

Coaching program development involved several layers of collaboration between health-care system leaders, faculty educators, and departmental communication champions. The efforts included: (1) creating and delivering communication skills training to faculty and residents; (2) hosting frequent meetings among various stakeholders to develop program strategy, discuss opportunities and learnings, and engage other medical educators interested in coaching; (3) obtaining funding to implement the coaching initiative; (4) selecting coaches and providing salary and training support.

Evaluation

A multi-phased mixed-methods study utilized online surveys and virtual semi-structured interviews to assess the program's quality and impact on the communication culture and the satisfaction and communication skills of residents. Quantitative and qualitative data have been integrated during data collection and analysis using embedding, building, and merging strategies.

Discussion and Implications

Establishing a multi-departmental coaching program may be feasible and can be adapted by other programs if similar resources and focus are present. We found that stakeholders' buy-in, financial support, protected faculty time, flexible approach, and rigorous evaluation are crucial factors in successfully implementing and sustaining such an initiative.

A rare neuromyelitis optica mimic: Primary CNS histiocytic sarcoma

Primary central nervous system (CNS) histiocytic sarcoma is a rare hematolymphoid malignancy with features of mature histiocytes and carries a poor prognosis. We describe a unique case in which a 50-year-old woman presented with recurrent acute brainstem syndrome, area postrema syndrome, and myelitis with corresponding magnetic resonance imaging (MRI) lesions meeting diagnostic criteria for seronegative neuromyelitis optica spectrum disorder (NMOSD). Despite initial improvement with steroids and plasma exchange, she experienced recurrent symptoms over 10 months referable to new and persistently enhancing lesions. At autopsy, neuropathology revealed a diffusely infiltrative primary CNS histiocytic sarcoma. This case represents a rare clinicoradiologic mimic of NMOSD, underscoring the importance of evaluation for infiltrative diseases in cases of atypical seronegative NMOSD.

Impact of a relationship-centered care communication curriculum on pediatric residents' practice, perspectives, and opportunities to Develop expertise

OBJECTIVES

To investigate the impacts of a Relationship-Centered Care (RCC) communication curriculum with coaching on pediatric residents 1) self-reported use of RCC strategies and perspectives, and 2) opportunities to develop adaptive expertise.

METHODS

Residents (n = 77) completed a 4 h RCC training and shared resultant RCC goals with Coaches (n = 15). Data included resident surveys and reflections immediately post-training, and resident and coach surveys 6-months later. Reported use of RCC strategies were compared over time with paired t-tests. Qualitative data were analyzed using open coding guided by sensitizing principles from the RCC framework and adaptive expertise.

RESULTS

Pediatric residents reported significant increases (p < 0.001) in use of 4/9 RCC strategies after 6 months: eliciting all concerns, chunking information, checking for understanding, and teach-back. Resident reflections highlighted shifts in perspective around RCC. Training combined with coaching provided opportunities for residents to develop adaptive expertise through adapting and innovating across settings and contexts.

CONCLUSION

Residents had significant increases in reported use of key RCC strategies after a training combined with coaching and demonstrated opportunities to develop adaptive expertise.

PRACTICE IMPLICATIONS

Residency programs should include RCC training with an emphasis on the new and challenging strategies and provide opportunities to practice and receive coaching.

Outcomes of a Neurohospitalist Program at an Academic Medical Center

Background and Purpose

The purpose is to determine the impact of an academic neurohospitalist service on clinical outcomes.

Methods

We performed a retrospective, quasi-experimental study of patients discharged from the general neurology service before (August 2010–July 2014) and after implementation of a full-time neurohospitalist service (August 2016–July 2018) compared to a control group of stroke patients. Primary outcomes were length of stay and 30-day readmission. Using the difference-in-difference approach, the impact of introducing a neurohospitalist service compared to controls was assessed with adjustment of patients’ characteristics. Secondary outcomes included mortality, in-hospital complications, and cost.

Results

There were 2706 neurology admissions (1648 general; 1058 stroke) over the study period. The neurohospitalist service was associated with a trend in reduced 30-day readmissions (ratio of ORs: .52 [.27, .98], P = .088), while length of stay was not incrementally changed in the difference-in-difference model (-.3 [-.7, .1], P = .18). However, descriptive results demonstrated a significant reduction in mean adjusted LOS of .7 days (4.5 to 3.8 days, P < .001) and a trend toward reduced readmissions (8.9% to 7.6%, P = .42) in the post-neurohospitalist cohort despite a significant increase in patient complexity, shift to higher acuity diagnoses, more emergent admissions, and near quadrupling of observation status patients. Mortality and in-hospital complications remained low, patient satisfaction was stable, and cost was not incrementally changed in the post-neurohospitalist cohort.

Conclusions

Implementation of a neurohospitalist service at an academic medical center is feasible and associated with a significant increase in patient complexity and acuity and a trend toward reduced readmissions.

Patient and Clinician Perspectives of New and Return Ambulatory Teleneurology Visits

BACKGROUND AND OBJECTIVES

To evaluate the adoption and perceived utility of video visits for new and return patient encounters in ambulatory neurology subspecialties.

METHODS

Video visits were launched in an academic, multi-subspecialty, ambulatory neurology clinic in March 2020. Adoption of video visits for new and return patient visits was assessed using clinician-level scheduling data from March 22 to May 16, 2020. Perceived utility of video visits was explored via a clinician survey and semistructured interviews with clinicians and patients/caregivers. Findings were compared across 5 subspecialties and 2 visit types (new vs return).

RESULTS

Video visits were adopted rapidly; all clinicians (n = 65) integrated video visits into their workflow within the first 6 weeks, and 92% of visits were conducted via video, although this varied by subspecialty. Utility of video visits was higher for return than new patient visits, as indicated by surveyed (n = 48) and interviewed clinicians (n = 30), aligning with adoption patterns. Compared with in-person visits, clinicians believed that it was easier to achieve a similar physical examination, patient-clinician rapport, and perceived quality of care over video for return rather than new patient visits. Of the 25 patients/caregivers interviewed, most were satisfied with the care provided via video, regardless of visit type, with the main limitation being the physical examination.

DISCUSSION

Teleneurology was robustly adopted for both new and return ambulatory neurology patients during the COVID-19 pandemic. Return patient visits were preferred over new patient visits, but both were feasible. These results provide a foundation for developing targeted guidelines for sustaining teleneurology in ambulatory care.

Quality Improvement Metrics and Methods for Neurohospitalists

Measurement of clinical performance is largely driven by the requirements of the Centers for Medicare and Medicaid Services and accrediting bodies like The Joint Commission. Performance measures include length of stay, readmission rate, mortality rate, hospital-acquired complications, and stroke core measures. Hospital rankings also depend heavily on quality and patient safety indicators. Becoming facile with these measures can aid neurohospitalists in understanding their value and garnering resources to support improvement projects. Neurohospitalists can apply a structured A3-based method to define a clinical problem, perform systematic analysis, then design and test solutions to drive improved outcomes for patients with neurologic disease.

Detection of Neoplasms by Metagenomic Next-Generation Sequencing of Cerebrospinal Fluid

Importance

Cerebrospinal fluid (CSF) cytologic testing and flow cytometry are insensitive for diagnosing neoplasms of the central nervous system (CNS). Such clinical phenotypes can mimic infectious and autoimmune causes of meningoencephalitis.

Objective

To ascertain whether CSF metagenomic next-generation sequencing (mNGS) can identify aneuploidy, a hallmark of malignant neoplasms, in difficult-to-diagnose cases of CNS malignant neoplasm.

Design, Setting, and Participants

Two case-control studies were performed at the University of California, San Francisco (UCSF). The first study used CSF specimens collected at the UCSF Clinical Laboratories between July 1, 2017, and December 31, 2019, and evaluated test performance in specimens from patients with a CNS malignant neoplasm (positive controls) or without (negative controls). The results were compared with those from CSF cytologic testing and/or flow cytometry. The second study evaluated patients who were enrolled in an ongoing prospective study between April 1, 2014, and July 31, 2019, with presentations that were suggestive of neuroinflammatory disease but who were ultimately diagnosed with a CNS malignant neoplasm. Cases of individuals whose tumors could have been detected earlier without additional invasive testing are discussed.

Main Outcomes and Measures

The primary outcome measures were the sensitivity and specificity of aneuploidy detection by CSF mNGS. Secondary subset analyses included a comparison of CSF and tumor tissue chromosomal abnormalities and the identification of neuroimaging characteristics that were associated with test performance.

Results

Across both studies, 130 participants were included (median [interquartile range] age, 57.5 [43.3-68.0] years; 72 men [55.4%]). The test performance study used 125 residual laboratory CSF specimens from 47 patients with a CNS malignant neoplasm and 56 patients with other neurological diseases. The neuroinflammatory disease study enrolled 12 patients and 17 matched control participants. The sensitivity of the CSF mNGS assay was 75% (95% CI, 63%-85%), and the specificity was 100% (95% CI, 96%-100%). Aneuploidy was detected in 64% (95% CI, 41%-83%) of the patients in the test performance study with nondiagnostic cytologic testing and/or flow cytometry, and in 55% (95% CI, 23%-83%) of patients in the neuroinflammatory disease study who were ultimately diagnosed with a CNS malignant neoplasm. Of the patients in whom aneuploidy was detected, 38 (90.5%) had multiple copy number variations with tumor fractions ranging from 31% to 49%.

Conclusions and Relevance

This case-control study showed that CSF mNGS, which has low specimen volume requirements, does not require the preservation of cell integrity, and was orginally developed to diagnose neurologic infections, can also detect genetic evidence of a CNS malignant neoplasm in patients in whom CSF cytologic testing and/or flow cytometry yielded negative results with a low risk of false-positive results.

Feasibility and acceptability of virtually coaching residents on communication skills: a pilot study

BACKGROUND

Developing communication skills is a key competency for residents. Coaching, broadly accepted as a training modality in medical education, has been proven a successful tool for teaching communication skills. Little research is available thus far to investigate virtual coaching on communication skills for telemedicine encounters. The purpose of the study was to test the hypothesis that virtually coaching residents on communication skills is feasible and acceptable. We surveyed 21 resident-faculty pairs participating in a "fully virtual" coaching session (patient, coach, and resident were virtual).

METHODS

We asked 50 neurology resident-faculty coach pairs to complete one "fully virtual" coaching session between May 20 and August 31, 2020. After each session, the resident and coach completed a 15-item survey, including Likert-style scale and open-ended questions, assessing feasibility and acceptability. Descriptive statistics and qualitative content and thematic analyses were performed.

RESULTS

Forty-two percent (21/50) of all eligible residents completed "fully virtual" coaching sessions. The overall survey response rate was 91 % (38/42). The majority of respondents agreed that the direct observation and debriefing conversation were easy to schedule and occurred without technical difficulties and that debriefing elements (self-reflection, feedback, takeaways) were useful for residents. Ninety-five percent of respondents rated the coach's virtual presence to be not at all disruptive to the resident-patient interaction. Virtual coaching alleviated resident stress associated with observation and was perceived as an opportunity for immediate feedback and a unique approach for resident education that will persist into the future.

CONCLUSIONS

In this pilot study, residents and faculty coaches found virtual coaching on communication skills feasible and acceptable for telemedicine encounters. Many elements of our intervention may be adoptable by other residency programs. For example, residents may share their communication goals with clinic faculty supervisors and then invite them to directly observe virtual encounters what could facilitate targeted feedback related to the resident's goals. Moreover, virtual coaching on communication skills in both the in-person and telemedicine settings may particularly benefit residents in challenging encounters such as those with cognitively impaired patients or with surrogate decision-makers.

Neurohospitalist Practice and Well-Being During the COVID-19 Pandemic

Background and Purpose

Neurohospitalists play an important role in, and have been variably affected by, the ongoing COVID-19 pandemic. In this study, we survey neurohospitalists to characterize practice changes and the impact of the pandemic on their well-being.

Methods

A 22-item survey was distributed to neurohospitalists through the Neurohospitalist Society and the American Academy of Neurology Neurohospitalist, Stroke & Vascular Neurology, and Critical Care & Emergency Neurology Sections.

Results

After 2 weeks of collection, 123 responses were received, with 57% of respondents practicing in academic settings, 23% in private practice, and 7% in community hospitals. A minority of neurohospitalists (8%) were redeployed to care for COVID-19 or non-COVID-19 medicine patients. The most common neurologic diagnoses they reported in COVID-19 patients were delirium (85%), cerebrovascular events (75%), and seizure (35%); however, most neurohospitalists (59%) had evaluated fewer than 10 patients with COVID-19. Respondents observed that fewer patients with unrelated neurological diseases were admitted to the hospital compared to before the pandemic. Neurohospitalists experienced changes in administrative (27%), educational (15%), and research duties (11%), and had overall worse well-being and work-life balance (77%).

Conclusions

The most common neurologic diagnoses seen in COVID-19 patients by neurohospitalists in this sample are delirium, cerebrovascular disease, and seizure. Though the majority of survey respondents reported not being primary frontline providers, they report key clinical and operational roles during the pandemic, and report worse well-being as compared to before the pandemic. Our data suggests that there are opportunities to improve neurohospitalists' experience through flexible work practices and providing family care support.

Administration of Dexamethasone for Bacterial Meningitis: An Unreliable Quality Measure

Objective

To validate the use of administrative data to identify patients with bacterial meningitis and quantify the rate of dexamethasone administration as defined in the American Academy of Neurology Inpatient and Emergency Care Quality Measurement Set.

Methods

The Vizient Clinical Data Base and Resource Manager was used to identify patients with International Classification of Diseases, Tenth Revision (ICD-10) codes for bacterial meningitis from October 2015 to June 2019. Chart review was performed on patients identified at a single quaternary-care hospital. The positive predictive value (PPV) of Vizient was determined. Demographic, clinical, and laboratory data were assessed using descriptive statistics.

Results

Of all hospitals that submitted complete data to Vizient during the study period, a median of 19 patients per hospital had ICD-10 codes for bacterial meningitis in the 45-month period. We identified 79 patients using Vizient at our institution of whom 69 had a diagnosis of bacterial meningitis confirmed by chart review (PPV = 87%). 15 patients were eligible to receive dexamethasone per the quality measurement set. Six of these patients (40%) received dexamethasone.

Conclusion

It is feasible to use the Vizient Clinical Data Base and Resource Manager to identify patients with bacterial meningitis. Due to low prevalence across multiple institutions and high rate of exclusion criteria at our institution, this study suggests that the rate of dexamethasone administration in bacterial meningitis may be an unreliable indicator of quality of care provided by inpatient neurologists. The creation of a registry for hospitalized neurology patients could enhance development of future quality measures.

Rapid Implementation of Video Visits in Neurology During COVID-19: Mixed Methods Evaluation

BACKGROUND

Telemedicine has been used for decades. Despite its many advantages, its uptake and rigorous evaluation of feasibility across neurology's ambulatory subspecialties has been sparse. However, the COVID-19 pandemic prompted health care systems worldwide to reconsider traditional health care delivery. To safeguard health care workers and patients, many health care systems quickly transitioned to telemedicine, including across neurology subspecialties, providing a new opportunity to evaluate this modality of care.

OBJECTIVE

To evaluate the accelerated implementation of video visits in ambulatory neurology during the COVID-19 pandemic, we used mixed methods to assess adoption, acceptability, appropriateness, and perceptions of potential sustainability.

METHODS

Video visits were launched rapidly in ambulatory neurology clinics of a large academic medical center. To assess adoption, we analyzed clinician-level scheduling data collected between March 22 and May 16, 2020. We assessed acceptability, appropriateness, and sustainability via a clinician survey (n=48) and semistructured interviews with providers (n=30) completed between March and May 2020.

RESULTS

Video visits were adopted rapidly; overall, 65 (98%) clinicians integrated video visits into their workflow within the first 6 implementation weeks and 92% of all visits were conducted via video. Video visits were largely considered acceptable by clinicians, although various technological issues impacted their satisfaction. Video visits were reported to be more convenient for patients, families, and caregivers than in-person visits; however, access to technology, the patient's technological capacity, and language difficulties were considered barriers. Many clinicians expressed optimism about future utilization of video visits in neurology. They believed that video visits promote continuity of care and can be incorporated into their practice long-term, although several insisted that they can never replace the in-person examination.

CONCLUSIONS

Video visits are an important addition to clinical care in ambulatory neurology and are anticipated to remain a permanent supplement to in-person visits, promoting patient care continuity, and flexibility for patients and clinicians alike.

Accelerated launch of video visits in ambulatory neurology during COVID-19: Key lessons from the Stanford experience

The SARS-CoV-2 (COVID-19) pandemic has rapidly moved telemedicine from discretionary to necessary. Here, we describe how the Stanford Neurology Department (1) rapidly adapted to the COVID-19 pandemic, resulting in over 1,000 video visits within 4 weeks, and (2) accelerated an existing quality improvement plan of a tiered roll out of video visits for ambulatory neurology to a full-scale roll out. Key issues we encountered and addressed were related to equipment/software, provider engagement, workflow/triage, and training. On reflection, the key drivers of our success were provider engagement and dedicated support from a physician champion, who plays a critical role understanding stakeholder needs. Before COVID-19, physician interest in telemedicine was mixed. However, in response to county and state stay-at-home orders related to COVID-19, physician engagement changed completely; all providers wanted to convert a majority of visits to video visits as quickly as possible. Rapid deployment of neurology video visits across all its subspecialties is feasible. Our experience and lessons learned can facilitate broader utilization, acceptance, and normalization of video visits for neurology patients in the present as well as the much anticipated postpandemic era.

Education Research: A novel resident-driven neurology quality improvement curriculum

OBJECTIVE

To describe and assess the effectiveness of a neurology resident quality improvement curriculum focused on development of practical skills and project experience.

METHODS

We designed and implemented a quality improvement curriculum composed of (1) a workshop series and (2) monthly resident-led Morbidity, Mortality, & Improvement conferences focused on case analysis and project development. Surveys were administered precurriculum and 18 months postcurriculum to assess the effect on self-assessed confidence with quality improvement skills, attitudes, and project participation. Scholarship in the form of posters, presentations, and manuscripts was tracked during the course of the study.

RESULTS

Precurriculum, 83% of neurology residents felt that instruction in quality improvement was important, but most rated their confidence level with various skills as low. Following implementation of the curriculum, residents were significantly more confident in analyzing a patient case (odds ratio, 95% confidence interval) (2.4, 1.9-3.1), proposing system changes (3.1, 2.3-3.9), writing a problem statement (9.9, 6.2-13.5), studying a process (3.1, 2.3-3.8), identifying resources (3.1, 2.3-3.8), identifying appropriate measures (2.5, 1.9-3.0), collaborating with other providers to make improvements (4.9, 3.5-6.4), and making changes in a system (3.1, 2.3-3.8). Project participation increased from the precurriculum baseline (7/18, 39%) to the postcurriculum period (17/22, 77%; p = 0.023). One hundred percent of residents surveyed rated the curriculum positively.

CONCLUSIONS

Our multifaceted curriculum was associated with increased resident confidence with quality improvement skills and increased participation in improvement projects. With adequate faculty mentorship, this curriculum represents a novel template for preparing neurology residents for meeting the expectations of improvement in practice and offers scholarship opportunities.

Eponyms are here to stay

Objective

To assess the historical trends of medical eponym use in neurology literature and knowledge and attitudes among current trainees related to eponyms.

Methods

A comprehensive list of medical eponyms compiled from multiple online and print sources was queried against the titles and abstracts of PubMed articles authored by neurologists to assess historical prevalence in the literature from 1988 to 2013. We also surveyed current neurology trainees and trainees who have matched for residency in neurology, but not yet started neurology training, on their familiarity and attitudes toward eponyms.

Results

The yearly prevalence of eponyms among neurologist-authored publications ranged from 15% and 25%, with a mean of 21%. The total number of unique eponyms appearing in titles and abstracts increased from 693 in 1988 to 1,076 in 2013, representing 1.8% average annual growth. Our survey showed that residents with at least 1 year of neurology training reported familiarity with significantly more eponyms than those before neurology training (p < 0.001). For familiar eponyms, most residents were either unaware of an alternative descriptor or preferred using the eponym. Despite recognizing both the benefits and drawbacks of eponyms, the vast majority of trainees stated that historical precedent, pervasiveness, and ease of use would drive the continued use of eponyms in neurology.

Conclusions

Eponyms will remain a cornerstone in medical education and communication moving forward. Educators in neurology should consider how best to integrate useful eponyms and alternative descriptors into residency training to enhance knowledge acquisition and retention.

A Standardized Checklist Improves the Transfer of Stroke Patients from the Neurocritical Care Unit to Hospital Ward

Background and Purpose

The transfer of patients with ischemic stroke from the intensive care unit (ICU) to noncritical care inpatient wards involves detailed information sharing between care teams. Our local transfer process was not standardized, leading to potential patient risk. We developed and evaluated an "ICU Transfer Checklist" to standardize communication between the neurocritical care team and the stroke ward team.

Methods

Retrospective review of consecutive patients with ischemic stroke admitted to the neurocritical care unit who were transferred to the stroke ward was used to characterize transfer documentation. A multidisciplinary team developed and implemented an ICU Transfer Checklist that contained a synthesis of the patient's clinical course, immediate "to-do" action items, and a system-based review of active medical problems. Postintervention checklist utilization was recorded for 8 months, and quality metrics for the postintervention cohort were compared to the preintervention cohort. Providers were surveyed pre- and postintervention to characterize perceived workflow and quality of care.

Results

Patients before (n = 52) and after (n = 81) ICU Transfer Checklist implementation had similar demographic and clinical characteristics. In the postchecklist implementation period, the ICU Transfer Checklist was used in over 85% of patients and median hospital length of stay (LOS) decreased (8.6 days vs 5.4 days, P = .003), while ICU readmission rate remained low. The checklist was associated with improved perceptions of safety and decreased time needed to transfer patients.

Conclusions

Use of the standardized ICU Transfer Checklist was associated with decreased hospital LOS and with improvements in providers' perceptions of patient safety.

Education Research: Understanding barriers to goals of care communication for neurology trainees

Objective

To describe the perspectives of neurology residents regarding barriers to effective goals of care discussions and to identify residents' current and desired educational strategies to improve goals of care communication.

Methods

All neurology residents at our institution were invited to voluntarily participate in focus groups. Residents were organized into 3 focus groups by year of training. Moderators asked residents open-ended questions about current goals of care communication practice and ideas for improving the frequency and effectiveness of goals of care discussions. All responses were audiorecorded, transcribed, and de-identified. Transcripts of the focus groups were independently read and coded by members of the research team. We performed thematic analysis to identify and systematize relationships across coded data.

Results

Twenty out of 29 neurology residents participated in the focus groups. We identified 3 overarching domains impeding goals of care communication: patient factors, resident factors, and systems factors. Residents proposed specific desired strategies to address these 3 domains with the goal of improving the frequency and efficacy of goals of care communication. The desired strategies included receiving feedback from patients and families, developing resident-focused educational opportunities through direct observation and coaching, and systems changes by documenting goals of care discussions.

Conclusions

Neurology residents identify multiple barriers to effective goals of care communication and propose specific desired strategies for improvement. This detailed input from residents will be incorporated into future curricular interventions to improve confidence and skill in leading goals of care discussions.

National Variability in Prion Disease-Related Safety Policies for Neurologic Procedures

Prion diseases are fatal neurodegenerative disorders that can be transmitted via contact with infective tissue. Variability in hospital safety policies related to prion disease may place health-care workers at risk. We sought to assess variability of safety policies related to prion disease for neurosurgical procedures and lumbar punctures among neurological institutions in the United States. We e-mailed neurologists associated with 2016 US News and World Report "Top 50" Neurology & Neurosurgery Institutions to request hospital policies regarding safety precautions related to prion disease. For institutional surgical policies, the main outcome was concordance with each of the 8 specific precautions described in World Health Organization (WHO) guidelines published in 1999. No similar guidelines are available for lumbar puncture, so themes were identified and quantified among the lumbar puncture policies we collected. Of the 51 institutions contacted, there were 38 responses. Two institutions did not have relevant policies and 3 institutions declined to share their policies, yielding 33 institutional policies for review. Of these, 85% had a surgical policy and 54% had a lumbar puncture policy. Concordance with all 8 specific precautions described in the WHO guidelines was found in 14% of surgical policies. Lumbar puncture policies demonstrated variability in methods of waste disposal and decontamination procedures. There is significant variability in policies regarding safety precautions in patients with suspected prion disease. We advocate for the formation of national or international committees to examine this issue, set new guidelines, and foster implementation at the level of individual institutions.

Coexistence of Neuromyelitis Optica and Amyotrophic Lateral Sclerosis: A Case Report

The occurrence of amyotrophic lateral sclerosis (ALS) and neuromyelitis optica (NMO) in a single patient is exceedingly rare. We report a case of a 54-year-old woman of East Asian descent with a prior diagnosis of ALS who developed an episode of unexplained hiccups and nausea and vomiting consistent with area postrema syndrome 3 months prior to the onset of acute transverse myelitis. Magnetic resonance imaging revealed abnormal T2 hyperintensity and gadolinium enhancement at the cervicomedullary junction with extension to C3. Imaging was also notable for nonenhancing central cord T2 hyperintensity from T6 to T8 suggesting previous demyelination. The patient's cerebrospinal fluid analysis was mildly inflammatory. She was found to have a positive NMO/aquaporin-4 immunoglobulin G titer (cell-based assay) greater than 1:100 000, consistent with a diagnosis of NMO. The unusual coexistence of ALS and NMO prompts consideration of potential common pathological neuroinflammatory processes.

Unplanned Transfers from Hospital Wards to the Neurological Intensive Care Unit

BACKGROUND

The aim of this study is to evaluate the characteristics of unplanned transfers of adult patients from hospital wards to a neurological intensive care unit (NICU).

METHODS

We retrospectively reviewed consecutive unplanned transfers from hospital wards to the NICU at our institution over a 3-year period. In-hospital mortality rates were compared between patients readmitted to the NICU ("bounce-back transfers") and patients admitted to hospital wards from sources other than the NICU who were then transferred to the NICU ("incident transfers"). We also measured clinical characteristics of transfers, including source of admission and indication for transfer.

RESULTS

A total of 446 unplanned transfers from hospital wards to the NICU occurred, of which 39% were bounce-back transfers. The in-hospital mortality rate associated with all unplanned transfers to the NICU was 17% and did not differ significantly between bounce-back transfers and incident transfers. Transfers to the NICU within 24 h of admission to a floor service accounted for 32% of all transfers and were significantly more common for incident transfers than bounce-back transfers (39 vs. 21%, p = .0002). Of patients admitted via the emergency department who had subsequent incident transfers to the NICU, 50% were transferred within 24 h of admission.

CONCLUSIONS

Unplanned transfers to an NICU were common and were associated with a high in-hospital mortality rate. Quality improvement projects should target the triage process and transitions of care to the hospital wards in order to decrease unplanned transfers of high-risk patients to the NICU.

Electrographic Correlates of Plateau Waves in Patients With Leptomeningeal Metastases

We describe video electroencephalography (video-EEG) correlates of transient neurological attacks due to plateau waves-paroxysmal elevations in intracranial pressure-in patients with leptomeningeal metastases. We identified 3 patients with leptomeningeal metastases, intracranial hypertension, and transient neurological attacks captured on video-EEG without evidence of seizures or epileptiform activity. We identified all clinical events on video and reviewed the corresponding EEG data for evidence of abnormalities. All 3 patients had mild to moderate slowing and 2 had frontal intermittent rhythmic delta activity during background EEG recording. There were 33 clinical events recorded and stereotyped for each patient. All 33 events were associated with an increase in delta range slowing of ≥30% compared to the background. This abnormality started ≤2 minutes before the onset of clinical symptoms and persisted for minutes after clinical resolution. This study is the first to carefully describe the electrographic correlates of transient neurological attacks due to plateau waves in patients with leptomeningeal metastasis. Clinical attacks were consistently associated with a possible EEG signature of diffuse delta range slowing. Future studies can validate the sensitivity and specificity of these EEG changes as a prognostic and/or response biomarker in patients with leptomeningeal metastases with or without intracranial hypertension.

Mitochondrial myopathy with dystrophic features due to a novel mutation in the MTTM gene

INTRODUCTION

A 61-year-old woman with a 5-year history of progressive muscle weakness and atrophy had a muscle biopsy characterized by a combination of dystrophic features (necrotic fibers and endomysial fibrosis) and mitochondrial alterations [ragged-red, cytochrome c oxidase (COX)-negative fibers].

METHODS

Sequencing of the whole mtDNA, assessment of the mutation load in muscle and accessible nonmuscle tissues, and single fiber polymerase chain reaction.

RESULTS

Muscle mitochondrial DNA (mtDNA) sequencing revealed a novel heteroplasmic mutation (m.4403G>A) in the gene (MTTM) that encodes tRNA(Met). The mutation was not present in accessible nonmuscle tissues from the patient or 2 asymptomatic sisters.

CONCLUSIONS

The clinical features and muscle morphology in this patient are very similar to those described in a previous patient with a different mutation, also in MTTM, which suggests that mutations in this gene confer a distinctive "dystrophic" quality. This may be a diagnostic clue in patients with isolated mitochondrial myopathy.

Discrimination and reliance on conceptual fluency cues are inversely related in patients with mild Alzheimer's disease

Prior work suggests that patients with mild Alzheimer's disease (AD) often base their recognition memory decisions on familiarity. It has been argued that conceptual fluency may play an important role in the feeling of familiarity. In the present study we measured the effect of conceptual fluency manipulations on recognition judgments of patients with mild AD and older adult controls. "Easy" and "hard" test conditions were created by manipulating encoding depth and list length to yield high and low discrimination, respectively. When the two participant groups performed identical procedures, AD patients displayed lower discrimination and greater reliance on fluency cues than controls. However, when the discrimination of older adult controls was decreased to the level of AD patients by use of a shallow encoding task, we found that controls reliance on fluency did not statistically differ from AD patients. Furthermore, we found that increasing discrimination using shorter study lists resulted in AD patients decreasing their reliance on fluency cues to a similar extent as controls. These findings support the notion that patients with AD are able to attribute conceptual fluency to prior experience. In addition, these findings suggest that discrimination and reliance on fluency cues may be inversely related in both AD patients and older adult controls.

Memory loss in Alzheimer's disease: implications for development of therapeutics

Alzheimer's disease (AD) is a progressive neurodegenerative disease marked by a constellation of cognitive disturbances, the earliest and most prominent being impaired episodic memory. Episodic memory refers to the memory system that allows an individual to consciously retrieve a previously experienced item or episode of life. Many recent studies have focused on characterizing how AD pathology impacts particular aspects of episodic memory and underlying mental and neural processes. This review summarizes the findings of those studies and discusses the effects of current and promising treatments for AD on episodic memory. The goal of this review is to raise awareness of the strides that cognitive neuroscientists have made in understanding intact and dysfunctional memory. Knowledge of the specific memorial processes that are impaired in AD may be of great value to basic scientists developing novel therapies and to clinical researchers assessing the efficacy of those therapies.

Conceptual fluency at test shifts recognition response bias in Alzheimer's disease: implications for increased false recognition

The presence or absence of conceptual information in pictorial stimuli may explain the mixed findings of previous studies of false recognition in patients with mild Alzheimer's disease (AD). To test this hypothesis, 48 patients with AD were compared to 48 healthy older adults on a recognition task first described by Koutstaal et al. [Koutstaal, W., Reddy, C., Jackson, E. M., Prince, S., Cendan, D. L., & Schacter D. L. (2003). False recognition of abstract versus common objects in older and younger adults: Testing the semantic categorization account. Journal of Experimental Psychology: Learning, Memory, and Cognition, 29, 499-510]. Participants studied and were tested on their memory for categorized ambiguous pictures of common objects. The presence of conceptual information at study and/or test was manipulated by providing or withholding disambiguating semantic labels. Analyses focused on testing two competing theories. The semantic encoding hypothesis, which posits that the inter-item perceptual details are not encoded by AD patients when conceptual information is present in the stimuli, was not supported by the findings. In contrast, the conceptual fluency hypothesis was supported. Enhanced conceptual fluency at test dramatically shifted AD patients to a more liberal response bias, raising their false recognition. These results suggest that patients with AD rely on the fluency of test items in making recognition memory decisions. We speculate that AD patients' over reliance upon fluency may be attributable to (1) dysfunction of the hippocampus, disrupting recollection, and/or (2) dysfunction of prefrontal cortex, disrupting post-retrieval processes.

The effect of prophylactic knee bracing on performance

This study examined the effect of prophylactic knee bracing upon performance in 35 college-aged athletes. Twenty-five male and ten female subjects completed two sets of tests to determine quadriceps peak torque, rise time, time to fatigue, anaerobic power, and blood lactate accumulation. On one trial the subjects wore a Stromgren dual-hinged prophylactic knee brace. MANOVA analysis revealed that bracing did not significantly affect the performance of football players (males) but did inhibit the overall performance of lacrosse players (females) (P less than 0.05). Post hoc analyses determined that rise time (time to develop peak torque) was the greatest contributor among the dependent variables to the multivariate difference observed in the females. However, no isolated variable was identified as significantly different between the conditions by repeated-measures t-tests. Additional analyses disclosed that familiarity with brace wearing, order of testing, or a trial effect (i.e., learning) did not alter the performance results. It was concluded that wearing a protective knee brace does not improve performance and may inhibit performance in some asymptomatic athletes. It is suggested that athletes and coaches reexamine the use of prophylactic braces based upon these findings and other research described in this paper.

The late life counseling service: a program for the elderly

Many old people who are trying to cope with crises in their lives at a time when their physical and emotional resources are lowered could benefit from mental health counseling. A special late counseling service was established for that population in Milwaukee County, despite initial cynicism about its usefulness from both senior citizens and mental health professionals. Minority, economically deprived, and handicapped clients are vigorously recruited. Services include initial and sometimes subsequent home visits; staff deal with such problems as strained family relationships, unhealthy dependencies, and depressions of varying degrees. The authors discuss the importance of home visits, thorough assessment of clients, and public education to overcome ageism in the community at large and among mental health professionals.