AAN.com Talks to Dr. Elkind About Teaching the Next Generation of Neurologists

May 21, 2009

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elkindMitchell S. V. Elkind, MD, MS, FAAN, is Associate Professor of Neurology at Columbia University, where he is a past director of the neurology residency program. In February, Elkind's paper, "Teaching the Next Generation of Neurologists," was published in Neurology®. He spoke with Daniel B. Hier, MD, MBA, FAAN, who is Associate Editor for Education for AAN.com.

AAN.com: In your recent article in Neurology you list several challenges neurology educators face in the future. I personally worry about the availability of faculty time to do teaching. Is this going to be a real issue? Are there any creative ways to reward faculty for teaching?

Elkind: I think this is already an issue. Many of my colleagues are concerned about their ability to provide teaching to students and residents when faced with the realities of billing and seeing more patients in their offices. Faculty need to be rewarded for their time spent teaching, and I don't think the rewards need to be particularly creative. Good old-fashioned dollars would be a nice start. Promotions and tenure systems that seriously reward teaching would also be good. Including teaching among the other activities, such as research and practice—which are fairly compensated—would seem to be a reasonable and straightforward approach. Inevitably, the public will realize that the future of quality care depends on real compensation for teaching, not only on lip service.

AAN.com: In your article, you emphasized the growth of neurological knowledge and the expansion of neurology subspecialties. Are you worried about the future of the general neurologist?

Elkind: No. The general neurologist will continue to be the major provider of neurological care in many communities, and particularly in those communities that cannot support many subspecialists. Many neurological disorders do not have specific subspecialists associated with them. And many patients will continue to want to have the personal attention and qualities that a generalist may best provide. The general neurologist will also continue to serve as an important teacher of residents and students. The responsibility of the neurology community should be to facilitate the future of general neurology as a viable career choice.

AAN.com: How will the training of Gen-Yers (Millennials) differ from that of Baby Boomers and Gen-Xers?

Elkind: I don't think we know the answer to that yet. But I do think it will differ. The Gen-Yers will be much more comfortable with accessing vast amounts of information and utilizing new technologies than many of their mentors. They may use networks of resources to accomplish their goals, for example, using listservs and email to seek answers to clinical questions. They are likely to embrace techniques such as telestroke and teleneurology, interacting with patients over the internet, and other electronic media. Their career goals and definitions of professionalism may also differ from those of older physicians. We already see to some extent a distancing between trainees and their patients as they become more reliant on technologies and sophisticated diagnostic testing. One crucial aspect of their training will be to maintain balance between the new advantages that technology confers and the recognition of the importance of the patient as the ultimate center of attention.

AAN.com: In your article you mentioned that we must teach future neurologists a "hidden curriculum" which covers topics beyond neurology. What does this encompass?

Elkind: The idea behind the hidden curriculum is that medicine today exists in a complex context that includes not only patient care and medical knowledge, but also many other aspects of health care delivery that influence the ability to practice medicine. Residents are already involved in learning a hidden curriculum. They do this without even realizing it. We are constantly throwing changes at them, and they must learn to adapt: Social Service rounds, switching to the electronic medical record, billing requirements, reorganizing schedules to accommodate duty hour restrictions.

All of these items, and many others, are part of the non-scientific curriculum, but they are crucial to the practice of medicine. These are things we deal with as practicing physicians, but learning them is not hard-wired in the brain. For research-oriented trainees, they must learn a different set of skills: budgeting, employee management, perhaps presentation skills. All of these skills are learned. Previously, we simply ignored them as a part of training. Referring to them as a hidden curriculum is simply making explicit what was always present and implied.

AAN.com: You raised the specter of the "end of rotations" for neurology residents. How do you see the venue of neurology training changing in the future?

Elkind: I wouldn't call it a specter and I don't think rotations will completely vanish. The idea is simply to point out that the traditional rotation structure may not be the best way to teach all aspects of neurology. Rotations may make scheduling easier, but they may not always be an effective arrangement for teaching some skills. Some skills, such as understanding the principles of research methods or evidence-based neurology, may be better learned through longer-term experiences. One-month research blocks, for example, are mostly a break from the wards.

AAN.com: We at AAN.com are fascinated by the growth of wikis, podcasts, and Web 2.0. How will these new technologies change neurology education?

Elkind: You should tell me! I don't know. But I think we should take the same sort of empirical, scientific approach that we use towards clinical neurology. We should try these different technologies. Some may appear sort of neat in the short-term, but may not have utility over the long-term. This is one area in particular in which Gen Y is likely to lead and teach us as much as we teach them. I suspect that the availability to see rare disorders and images online—and particularly the ability to see videos of movements and unusual findings online at the click of a mouse—will make it easier for trainees to see rare diseases that they wouldn't otherwise encounter. In the end, though, these are all tools: Nothing can replace the teaching provided by a flesh-and-blood expert clinician at the bedside.

AAN.com: I was intrigued that you mentioned simulation as a means of education. Do you think future trainees will spend time with simulated patients?

Elkind: The surgeons have already found that simulations provide an effective opportunity to practice and learn skills before encountering patients, and I suspect that neurology residents will also improve their skills using simulated patients or procedures. This is likely to be most useful in the case of procedures, such as EMGs and lumbar punctures—and procedures and treatments in critical care—in which decisions need to be made quickly and decisively. At present, of course, this remains mostly a hypothesis. Certainly this hypothesis needs to be tested!

Author Disclosures

Dr. Elkind reports no disclosures.

Dr. Hier received personal compensation for medical legal consulting and consulting to legal firms regarding medical malpractice issues within the past 24 months. In that period he also served as editor for MDnetguide, and has given expert testimony, prepared a deposition, and/or acted as a witness or consultant in medical malpractice cases. Dr. Hier receives personal compensation in an editorial capacity for AAN.com.