Megan Richie

While academic centers have traditionally valued faculty research and educational accomplishments, clinical excellence is often assumed or underappreciated. Accordingly, neurology residency programs frequently offer structured pathways for aspiring clinician-scientists or educators, but few offer dedicated training to launch residents into academic careers focused on clinical mastery. Guided by self-regulated learning principles and the Master Adaptive Learner framework, the aim of this curriculum was to equip neurology postgraduate year (PGY)-4 residents with the foundational skills of the master clinician by advancing the following: (1) clinical acumen and diagnostic reasoning; (2) a scholarly and evidence-informed approach to their work; (3) outstanding communication, professionalism, and humanism; and (4) effective navigation and leadership within complex health care systems. Using the Kern six-step curriculum design framework, we developed a 6-month Master Clinician track that included didactics, customized clinical rotations, reflective patient portfolios, and a scholarly project. Didactics addressed topics such as cognitive bias, adaptive expertise, communication, and clinical uncertainty. Clinical rotations were learning-focused experiences tailored to resident interests. Track residents maintained 2 patient portfolios: one for in-depth case analysis (“depth” portfolio) and another to track diagnostic accuracy (“breadth” portfolio). The scholarly project reinforced a reflective approach to patient care and promoted academic inquiry skills. Assessments of the track included an exit survey on completion, patient portfolio audits, and post-track surveys for 3 years after graduation from residency. Five residents completed the track in the first 5 years (2017–2022). Baseline residency milestone ratings were similar between participants and nonparticipants. Track components received high ratings (≥4.6 on a 5-point scale), with didactics on cognitive bias and teaching skills rated highest. Portfolios averaged 32 cases (breadth) and 8 cases (depth). Residents highlighted clinical uncertainty, communication, and cognitive bias as the most relevant sessions for patient care. Over 3 years of follow-up, high satisfaction with the track persisted and most enrollees elected academic clinical or clinician-educator careers. A residency track that used didactics, customized clinical experiences, case-tracking, and reflective practices to foster clinical excellence was well received by residents. Neurology programs should consider similar tracks to develop academic clinicians focused on excellence in patient care.

Background: Medical students transitioning to clerkships face new academic, social and emotional challenges in an unfamiliar learning environment. Medical student coaching has benefits for students' personal and professional development during the preclinical years, but there is limited literature studying its role in the clerkship year. Previous studies indicate that students have difficulty accessing coaching during clerkships, suggesting a missed opportunity to facilitate ongoing personal and professional development. Approach: We expanded coaching in the clerkship year by facilitating additional student–coach meetings covering topics such as feedback, wellness and career decision‐making. Seven coaches and 31 students participated in this pilot. Evaluation: We assessed effectiveness using a survey with Likert‐scale and open‐ended questions. Both students and coaches reported benefits related to support and reflection, the longitudinal relationship and professional development. Students found coaching added a unique and valuable perspective to their clerkship experience, stemming from the strong pre‐existing coaching relationship. Both groups identified scheduling meetings as the biggest challenge. An unexpected finding was the early identification of challenges students may be facing, with the potential for early support and mitigation. Implications: Our students and coaches find coaching during the clerkship year to be valuable and feasible, especially if coordinated with clerkships to reduce scheduling concerns. Results align with Gruppen's conceptual framework for learning environments: the benefits fall into the social and personal domains, with the challenge of scheduling highlighting the need for organizational support.

Pressures on academic physician educators to generate clinical revenue or research grants may threaten faculty engagement as teachers. Neurology has historically prized its outstanding educators, but programs that provide financial support for teaching are lacking. We developed an opt-in, financial, teaching incentive program in an academic neurology department and evaluated its impact on faculty experience, motivation, and identity. We applied a change management framework and conducted a National and local needs assessment before designing an education value unit (EVU) system using time-based metrics and rates reflecting impact on clinical revenue. Activities essential for graduation of students and residents that reduced clinical revenue generation were included. Faculty self-reported teaching through an online platform and received an incentive payment at the end of each year. Following a 6-month pilot, faculty participated in a 3-year implementation phase followed by an evaluation through faculty survey and semistructured interviews. In the first 3 years of the program, 42, 56, and 54 faculty enrolled, representing 28% of faculty by year 3. Faculty reported an average of 1,488 hours of teaching annually, drew from 13 divisions, and included all ranks (51% assistant, 29% associate, and 20% full). Fifty-five percent of participating faculty (N = 30) completed a survey to evaluate the incentive program. The majority agreed or somewhat agreed that the program had met its goals (80%–92%), reduced barriers to teaching (56%), and the department highly valued teaching (93%). Semistructured interviews with 11 participating faculty identified 5 themes regarding the impact of the program on faculty experience, including (1) supporting the choice of faculty to teach even when time is scarce, (2) making teaching visible to oneself and others, (3) directing faculty toward eligible teaching opportunities, (4) communicating the department's commitment to education, and (5) reinforcing educator identity and sense of belonging. The development of a teaching incentive program at an academic neurology center is feasible with benefits extending beyond the incentive payment itself. Although EVU programs are not without limitations, faculty experienced the program as reflective of the department valuing its educators, which reinforced their educator identity and engagement in teaching.

To report a case of adult-onset non-dystrophic myotonia complicated by recurrent episodes of laryngospasm. The patient is a 35-year-old man who was admitted to our hospital for recurrent episodes of apnea requiring endotracheal intubation with mechanical ventilation. He underwent extensive evaluation, including EMG, laryngoscopy, muscle biopsy, and genetic testing, which revealed a diagnosis of non-dystrophic myotonia. His myotonic disorder was due to the synergistic effects of a pathogenic CLCN1 variant and a newly reported SCN4A variant. His muscle biopsy demonstrated myofibrillar disorganization with Z-band streaming, which may reflect the severity of his clinical and electrographic myotonia. Treatment with mexiletine resulted in resolution of his episodes of laryngospasm and symptoms of myotonia in the extremities. Our case adds to the literature on the potentiating effects of chloride channelopathies on sodium channel myotonia. This is the first reported case of an adult-onset sodium channelopathy manifesting with respiratory failure due to laryngospasm. In addition, we present muscle biopsy findings that have not been described in the recent literature. This case also highlights that a myotonic disorder should be considered in the differential diagnosis for recurrent episodes of mixed hypoxic and hypercarbic respiratory failure.

The Neurohospitalist Core Competencies comprise a set of competency-based learning objectives that encapsulate the knowledge, skills, and attitudes of neurohospitalitists who specialize in the care of hospitalized patients with neurologic conditions. These competencies serve to characterize the rapidly expanding field of neurohospitalist medicine. The 27 chapters are divided into 3 sections entitled: neurological conditions, clinical interventions and interpretation of ancillary studies, and neurohospitalist role in the healthcare system. Each individual learning objective in the chapters describes a specific concept with an action verb to illustrate the behavior that the neurohospitalist exhibits. The individual neurohospitalist may not exhibit mastery in each of the topics included as individual practices vary in scope and practice pattern. A few examples of how the complete set of competencies may be used include in the creation of curricula for neurohospitalist fellowships, to assist in defining the scope of practice of neurohospitalists for administrative leaders of hospitals and departments, and in influencing the direction of further research and quality improvement in the field.

Background and Purpose: Neurohospitalists specialize in the care of hospitalized patients with neurological conditions. As the neurohospitalist model of patient care has grown rapidly and in diverse ways, there has been increasing demand for a formal definition of the field, particularly to support curriculum development for learners at multiple levels. Methods: The Neurohospitalist Society (NHS) formed a Core Competencies Committee in 2021. This committee defined the scope of the Neurohospitalist Core Competencies and organized the competency topics into chapters. This chapter list was approved by the members of the NHS. An open invitation was made to the general membership of the NHS to write chapters on a first-come, first-served basis, using a standardized chapter template developed by the Committee. A three-step editing process was completed, with members of the Committee serving as editors. A dissemination strategy was designed, including drafting of 2 manuscripts (the Core Competencies themselves, and this accompanying manuscript) and outreach to the general membership of the NHS. Results: The Neurohospitalist Core Competencies include 27 chapters divided into 3 sections: neurological conditions; clinical interventions and interpretations of ancillary studies; and neurohospitalist role in the health care system. The complete version of the Neurohospitalist Core Competencies is published as a separate manuscript in this issue of The Neurohospitalist. Conclusions: The creation of the Neurohospitalist Core Competencies was a multi-year initiative intended to support practicing neurohospitalists, trainees interested in pursuing careers in the field, medical education leaders, and administrative leaders of hospitals and departments.

We describe a case of a 41-year-old male with a history of end-stage renal disease, hypertension, epilepsy, ischemic stroke, and traumatic brain injury transferred to our tertiary care center for subacute, progressive cognitive impairment. He was found to have disproportionate brain atrophy, focal seizures, and refractory hypertension. Given suspicion for an underlying genetic etiology, a genetic panel for progressive renal disease was sent, revealing two known pathogenic variants in a gene for a cobalamin metabolism disorder, Cobalamin C deficiency. He was started on targeted metabolic supplementation with subsequent improvement in his cognition. Our case highlights the crucial need to expand diagnostic workup to include genetic and metabolic causes in patients with neurologic disease, atypical features, relevant family history and multi-organ dysfunction.

The association between brain injury after cardiac arrest and poor survival outcomes has led to longstanding pessimism. However, the publicly witnessed cardiac arrest, resuscitation, and acute management of Mr. Damar Hamlin and his favorable neurologic recovery provides some optimism. Mr. Hamlin's case highlights the neurologic advances of the last 2 decades and presents the opportunity to improve outcomes for all cardiac arrest patients in key areas: (1) effectively implementing the American Heart Association “Chain of Survival” to prevent initial brain injury and promote neuroprotection; (2) revisiting the process of neurologic prognostication and re‐defining the brain recovery during the early periods, and (3) incorporating neurorehabilitation into existing cardiac rehabilitation models to support holistic recovery. ANN NEUROL 2023;93:871–876

BACKGROUND AND PURPOSE: The rate of abnormal intracranial MR imaging findings including subdural collections and dural enhancement after recent lumbar puncture is not known. The purpose of our study was to examine the intracranial MR imaging findings after recent image-guided lumbar puncture. MATERIALS AND METHODS: Patients who underwent contrast-enhanced MR imaging of the brain within 7 days of a CT-guided lumbar puncture between January 2014 and April 2021 were included. Contrast-enhanced MR images were reviewed for diffuse dural enhancement, morphologic findings of brain sag, dural venous sinus distension, and subdural collections. RESULTS: Of the 160 patients who met the inclusion criteria, only 6 patients (3.9%) had new diffuse dural enhancement, though none had dural enhancement when the MR imaging was within 2 days of lumbar puncture. All 6 patients with dural enhancement had small, concurrent subdural collections. Two additional patients had subdural collections, for a total of 5.2% of our population. CONCLUSIONS: Our study is the first to examine intracranial MR imaging after recent lumbar puncture and has 2 key findings: First, 5.2% of patients had small, bilateral subdural collections after recent lumbar puncture, suggesting that asymptomatic subdural collections after recent lumbar puncture are not atypical and do not require further work-up. Additionally, when MR imaging was performed within 2 days of lumbar puncture, none of our patients had diffuse dural enhancement. This argues against the commonly held practice of performing MR imaging before lumbar puncture to avoid findings of dural enhancement, and should not delay diagnostic work-up.