Neurology Education with Dr. Brian Hanrahan

In this episode, Dr. Brian Hanrahan, Assistant Program Director for the neurology residency at St. Luke’s and  Fellowship Director of Clinical Neurophysiology, shares his journey from resident to creating NowYouKnow Neuro, an educational platform for neurology trainees. 

• Check out our website at www.theneurotransmitters.com to sign up for emails, classes, and quizzes!
• Would you like to be a guest or suggest a topic? Email us at contact@theneurotransmitters.com
• Follow our podcast channel on 𝕏 @neuro_podcast for future news!
• Find me on 𝕏 @DrKentris

The views expressed do not necessarily represent those of any associated organizations. The information in this podcast is for educational and informational purposes only and does not represent specific medical/health advice. Please consult with an appropriate health care professional for any medical/health advice.

Transcript

Dr. Michael Kentris: 0:01

Hello and welcome back to the Neurotransmitters. I'm your host, dr Michael Kentris, and today I'm happy to revisit a subject very near and dear to my heart, and hopefully to yours as well, which is medical education in neurology. And to help me on that journey, today I'm happy to introduce Dr Brian Hanrahan. Please let everybody know kind of who you are, what you do.

Dr. Brian Hanrahan: 0:25

All right, michael, thank you very much for having me. It's a great honor to be here. So I am an assistant program director of neurology residency, as well as a fellowship director of clinical neurophysiology. I'm board certified in neurology, clinical neurophysiology and epilepsy. In addition to those clinical and medical educational roles, I'm also co-founder of the medical educational platform. Now you Know Neuro.

Dr. Michael Kentris: 0:50

Awesome. So I, as someone who also has engaged in the online space, kind of in the medical education space, kind of independently to an extent, I was really happy to hear from you and to kind of hear about sort of your journey from and we can go back as far as you want, whether med school residency or wherever you think it makes sense to kind of pick up the tail and kind of talk about how you went from kind of trainee to medical educator.

Dr. Brian Hanrahan: 1:19

Yeah, I love telling this story. So to be honest, I was always interested in education. My mom was an elementary school teacher. I grew up in a family of educators. In the elementary level I was the first physician in my family. I went to medical school and during my medical school years I still really enjoyed interacting with the clerkship directors and kind of learning how medical education was done.

Dr. Brian Hanrahan: 1:45

When I got into my neurology residency and I was starting to prepare for the in-service examinations, I just felt there really wasn't very good resources available for us to kind of optimize our knowledge and time to prepare for these things. So after I went to the AAN conferences at PGY2 and kind of just, you know, communicating with other leaders in the field, I kind of realized that this might be something I need to kind of tackle myself. So during my first, you know, pgy2, pgy3 years I started working on developing some text-based content for preparation for the in-service and board examinations. But I really didn't have an idea of how to kind of share that information in the future. I figured that would be a future problem for me.

Dr. Brian Hanrahan: 2:27

Fortunately, one of my junior residents, steve Gangloff, has a lot of experience in code coding and website design. So I met with him kind of the end of my PGY3 year, beginning of PGY4, and kind of gave him a pitch of what we think we could put together as an educational resource for residents and he was totally on board. So now that was about longer ago than I'd like to admit, probably about seven or eight years now. We had the website launched, probably around 2019. And then at that time it was primarily text-based chapters and an image database with radiology, eegs, emgs and pathology. But since then we really have kind of evolved into having many more modes of learning, including flashcards. We now have about a 1300 multiple choice question bank and slowly adding more audio visual content onto the site as well.

Dr. Michael Kentris: 3:27

Awesome, yeah, I remember coming across the website. Unfortunately, I had been, like you said, also longer than I care to admit, out of residency for a couple of years when I saw it out there and I do think back kind of to that landscape. Right, I took my boards in 2017. And, as you said, there were a handful of resources out there in terms of like. I was, fortunate enough, one of my attendings was Dr Esteban Ching Ching, who kind of put together the for any of the neurology residents out there, that uh kind of question comprehensive review in neurology, I think is the title, uh, which very uh frustrating book, but also very good as far as as a textbook is. And then everything else. It always seemed like, like you were saying, all these different residency programs had their own little pockets of like things that have been handed down generation of generation to resident but hadn't really been widespread, and it seems like this is kind of that writ large to an extent.

Dr. Brian Hanrahan: 4:36

Yeah, I mean it's something that has been grown and fostered from interacting with residents and leaders in medical education across the country. I think there's probably been 50 to 60 people that have touched it in some way, whether it's writing a question, reviewing a chapter, helping me with the flashcards, giving lectures. So many hands make light work and it's crazy to think kind of how large and robust it is at this point. And I think, mike, you hit a great point of that. You know smaller programs, newer programs, don't have that internal resource available. You can imagine, you know, when I became an assistant program director at my program, we just started it so we had to create a like 200 hour lecture series in the first year out of scratch.

Dr. Brian Hanrahan: 5:23

You know incredibly hard when you don't have that. You know those years of research or old lectures kind of build on to kind of get to the point where you're on the same tier as well. Established programs have been around for decades, not even longer. So this kind of helps programs kind of get to that level very quickly. And it's great to see how some training programs have incorporated my content into their curriculum. You know whether it's question, review or in some other modality, because it really. You know, it's very rewarding to me to kind of see the amount of influence I've been able to have in people that I might not even know personally myself, but it seems to have still some value.

Dr. Michael Kentris: 6:04

No, that's excellent. And one of the things I thought was interesting is that you know you do have on the website the option for, like, say, an institution subscription as well. And I'm just curious from your own perspective when, like, let's say, a residency program signs up for you know the a year or a board review series or what have you Does like, do they find that there is an objective increase in either board passing rates or in terms of their in-service exam scores going up? Or what kind of metrics do they report back to you, or what kind of feedback do you get from the users of your services?

Dr. Brian Hanrahan: 6:44

So subjectively, we get really great feedback.

Dr. Brian Hanrahan: 6:47

The one thing that we've kind of learned is if we set up an institutional account or even like a free trial for an institution, you know, in the time leading into the in-service exam or just at the beginning of the academic year, the retention rate is extremely high.

Dr. Brian Hanrahan: 7:00

So if people didn't like it or find it rewarding, they wouldn't continue to stay with us. It's a little harder to get that objective data because I think you know what metrics would we use. Necessarily, you know you could use board pass rates. You know, utilizing the in-service exam for something like this is something I think the AAM would probably not look kindly upon, probably not look kindly upon. They would probably frown upon that because of you know it's really a marker of academic performance and gives you insight into how your residents are performing and what you know deficits they may have that they can focus their attention on before the following year or before their boards. So it's been hard to kind of find that objective data, although we do have a lot of survey-based insights into the user experience and it's overall very positive.

Dr. Michael Kentris: 7:46

Yeah, no, that's a great point. I do remember as an anxious fourth-year resident myself, looking back to see like how you know, how worried do I need to be about my in-service exam scores versus my likelihood of passing my boards? I think I only found like one paper from like the early 2000s or 2010s that was looking at that Like there is an association. It was fairly strong, but not super robust. Um, but yeah, it is one of those things that, uh, I think you were absolutely right and you know we don't need to lean too much on the in-service exam as far as board passing rates and things like that, because that, as you rightly said, is not the intent of the test. It's not there to be a punishment or a scourge for those who didn't perform well. Hopefully more encouragement.

Dr. Brian Hanrahan: 8:40

Yeah, many PGY-2s come in thinking it's something as serious as like a shelf exam in medical school or something like that, and we kind of have to reassure them that no, that's not how this works. This is really just a marker. You know, only the academic leadership at your institution should know your performance and if anyone asks in your interview season, you've got to let us know, because they, you know, we actually. You know, I think the AAM encourages you to report that type of behavior. Yeah, another encourages you to report that type of behavior. Yeah, another thing to build on that Mike, you mentioned that research article. You're right, that was published by the AAN. I don't remember the exact numbers off my head, but I think there was like a 99 pass rate. If your score was like 65% or higher, yeah, so 65% of the question is correct, right.

Dr. Brian Hanrahan: 9:21

So that's pretty dated and the right exam has had some dramatically dramatic improvements in the curriculum, the question content, the image content, is now online based or, I guess, electronic instead of paper based with a pen and pencil, like you and I remember taking it like and squinting and couldn't see the pixelated gray figures. So they've done a great job improving that exam and they've made a lot of changes to reflect some of the blueprint for the ADP exam. So at the AAN conference this April they announced that they're going to do another review of the performance on the NSERF exam in relation to boards and hopefully that should be coming out in the next year or so. So I'm really curious to see what the new data is. Because the exam is now so dramatically different.

Dr. Brian Hanrahan: 10:12

Because that's really something that I need to know as a medical educator when I'm, you know, communicating with my trainees, because realistically I kind of want to know what is the threshold for my graduating class to perform at, for me to say you have nothing to worry about, or to put someone on alert and say, listen, you really need to buckle down and spend a lot more time learning and paying attention and focusing on these aspects. They do give you that kind of detailed breakdown of not only what subjects people struggled in but also what topics whether it's an easy, medium, hard they struggled in and also like at an institutional level too. So I think that's really great as a medical educator to review all that information to kind of, you know, potentially make some modifications to your curriculum in any individual year If you know that your school struggled in you know neuroinfectious diseases, that might be something you want to add one or two lectures on. You know in neuroinfectious diseases that might be something you want to add one or two lectures on.

Dr. Michael Kentris: 11:06

Incorporated throughout the academic year. No, that's great, and I do remember anecdotally my own scores and I like to think that they're fairly representative of most junior residents back then, which would have been like neuro-oncology pediatric neurology which would have been like like neuro-oncology, pediatric neurology, yeah, um, and then a lot of times, especially as a PGY2, like a lot of the pathology, like neuropath questions.

Dr. Michael Kentris: 11:34

Uh, those are always one of the things that are just like ripe for questions. Yeah, and I, I remember, as you said, it's it's someone who's a little bit away from that now and not working directly with neurology residents as often. Who's a little bit away from that now and not working directly with neurology residents as often um, there was. There was always a lot of complaining when the right uh right exam time came around, because there's like such a disconnect in terms of what they were asking you versus what you are likely to be seeing on your board exams that it was felt you know, to use some extreme language like a waste of time. Uh, uh, to an extent, which probably a bit of an over-exaggeration, but we all know how, how you can be when you're in residency and tired and frustrated, um, but yeah any core, any core faculty member in medical education, in neurology are going to hear that after the exam like, oh, they asked these mundane, intricate little questions.

Dr. Brian Hanrahan: 12:23

Um, but you know I always kind of explain.

Dr. Brian Hanrahan: 12:25

There's, you know, there's clinical fund of knowledge, like practice practicing fund of knowledge, and textbook or board exam fund of knowledge.

Dr. Brian Hanrahan: 12:33

And yes, there's significant overlap but there's a little bit on each side of those that are not going to be applicable to both and you just have to be aware of that and really focus your time when you are learning independently on those kinds of things that are outside that Venn diagram.

Dr. Brian Hanrahan: 12:49

I think one of the biggest criticisms you could have about the in-service exam as an adult neurology resident is that they do have a lot of pediatrics and a higher percentage of pediatric neurology on it compared to what you're going to be taking on the adult neurology board exam, and it's because it's created to be taken by both pediatric and adult neurology residents. There are some discussions again in April this year of possibly separating out the pediatric and the adult neurology residency and service examinations, which I actually think would be a great idea, because then you'd be able to have the exam more reflective of what those future trainees are going to take and with, I think, the team that they had in the AA, and I think they definitely would be able to create, um, you know, a question bank that would be large enough to be able to serve both of those means.

Dr. Michael Kentris: 13:38

No, that's a great point. I've I've heard similar discourse as well, uh, from some of our child neurology colleagues. I've heard similar discourse as well from some of our child neurology colleagues, and, yeah, it is one of these things where we see this continued I hate to use the word balkanization like even within neurology, adult neurology, and there's just such a vastness of information that it does become almost challenging to say, like, what should a graduating general neurologist know? And that's, I think, becoming a harder question to answer at times. I'm curious what your perspective is as someone in kind of more involved in training residents at present.

Dr. Brian Hanrahan: 14:19

Yeah. So it is definitely getting harder, I think, to figure out what esoteric information is really needed, and I think both you and me, Mike, now we've been around long enough, as much as we wouldn't like to admit to have seen that kind of evolve over time. Because I think historically there was a lot more neuropath evaluated, a lot more of the biochemistry, isosomal storage, diseases, things like that that are being incorporated, but now things are just a little bit easier to do. I think the role of a neurologist has evolved over time too, and I think one of the hard things too is just the evolving range of neuropharmacology available. If you think about just like all the MS therapies that have been approved in the last five years, it's overwhelming.

Dr. Brian Hanrahan: 15:08

And how much of all of that does a neurology resident need to know, being that they might not really be practicing that aspect in great detail? I think that's a big struggle that a lot of question exam companies struggle with, because when you are at creating, you know questions or teaching points that are really reflective of what a foundational trainee would need to know. So there's always that constant battle. So when we have like people contribute to now you know neuro, I actually usually like to have people that are more in the higher tiers of their graduate medical education or just out of training or in residence or in fellowship, because they kind of have a better idea of what that foundational knowledge is, as opposed to like that super sub specialized components.

Dr. Michael Kentris: 16:15

No, that's a that's a great point. It kind of puts me in mind of some of that YouTube video series where you know, like a physicist explains black holes at five different levels. You know down to, like a kid in a garden, or up to another another PhD.

Dr. Michael Kentris: 16:29

Yeah, Like you said. It's exactly what you said. You get these deep, deep, like they're at the cutting, bleeding edge of research and you get all this minutiae of these drugs coming down the pipeline and we think they get really mechanistic and maybe the general neurologist out there just needs to know do I need to check liver enzymes periodically on this medication, or what's up?

Dr. Brian Hanrahan: 17:01

When do I refer to a specialist?

Dr. Brian Hanrahan: 17:02

yes, exactly when do I submit them into the epilepsy monitoring unit, things like that, right, yeah, and I? That's that ability to communicate at. You know, what I argue is like an eighth grade reading level is really also can be um valuable in patient care, right? One thing I've also have experienced when I work with newly graduated medical students in residency is that they have this huge fund of knowledge they want to show off right, because they've worked very hard to get to where they are. And then when they're communicating things to their patients, sometimes it's at a high level where you would need to have that graduate degree to fully comprehend the whole conversation level where you would need to have that graduate degree to fully comprehend the whole conversation. But being able to communicate that in a very easy way or really understandable way would be something that your patients are really going to appreciate, right, because then they actually have understanding of their own health.

Dr. Michael Kentris: 17:55

Yeah, I know I was guilty of this the other day because I always ask the patients when I'm explaining something how much do you want to know, right? So I was talking about functional neurologic disorders with someone and they wanted to know more. So I was like, so we talked about the interoceptive network for a few minutes, which I you know, to be honest. Right, it's one of those things that, again, right, we don't necessarily learn as much in residency, but you and I, we both did epilepsy fellowship and it's something we see all the time.

Dr. Michael Kentris: 18:31

So I have this book now on my shelf where I kind of go back. I got the clinical foundation, now I can go back and dive into some of the neuroscience. I got the clinical foundation. Now I can go back and dive into some of the neuroscience instead of being a pretend neuroscientist, try and get some of the actual foundational information there and read more about some of these things that I hear these researchers talking about. So I have some foundational understanding and hopefully I can use that information that I accrue to explain it in a more clear and concise manner, as opposed to, like you know, like uh, for those who are familiar like the common analogy uses, like the software hardware mismatch um, which, you know, not entirely accurate, right, like most analogies, it breaks down at some point, but but right. The more we know, the more creative we can be in terms of our descriptions and hopefully communicate things more accurately, kind of meeting the patient or the learner where they are.

Dr. Brian Hanrahan: 19:30

Yeah, also a good concept on top of that is he was like understanding what their, their understanding is of that diagnosis to begin with, right to begin with right. Especially again in that realm of conversion disorder or non-epileptic events, there is such a stigmatization of that. They may have been told that they're crazy, that they're doing some purpose. It's all in their head, like all these kind of huge things that are obviously nothing that any trained epileptologist would ever say in a patient room. It really kind of helps you get it up, preps you for that type of conversation and seeing how much empathy you know is needed to kind of convey some of these teaching points or these educational points for the patient.

Dr. Michael Kentris: 20:09

Absolutely. Now, one thing I'm curious to hear your perspective on is, you know so I was at a neurology residency for my first few years out of training and I moved and I'm currently at a community teaching hospital. So most of my educational role is dealing with non-neurology residents, so internal medicine, family medicine, emergency medicine and so kind of these frontline primary care physicians or physicians to be. Well, no, they're physicians, they're soon to be independent, and so getting them acclimated with common neurologic disorders that you know, I try and do my best to identify, like, what are the most important things that they need to know, if they're, you know, because there's plenty of neurology deserts throughout the country, you know, let alone throughout the world. So how can we get these primary care physicians to kind of get the essentials down so that they can hopefully manage some of the more common disorders out there? And I'm curious, like in someone who is in a more structured teaching role, how do you find that integrates into, kind of the overall structure of the neurology residency program?

Dr. Brian Hanrahan: 21:20

Yeah, I mean we have. I think every neurology residency program would probably still have trainees rotating on their services that are outside neurology, right, you know, if psychiatry has to do neurology exposures, internal medicine will come through. If you have neurosurgery, you know they may be rotating in your vascular neurology or in service services. And I think it's really important that you have some personalization based on you know the type of training that person has and also how much time you have with them. Right, you know if you only have, like you know, a week with them, you know how much are they going to get out of that.

Dr. Brian Hanrahan: 21:52

You're kind of limited and you're not going to cover all the bases, but whenever I do work with anyone outside of my residency program, I kind of always want to know what their future goals are regarding their career, like what career path they're going into. So then I can kind of modify my educational teaching points based on those components. Right, if someone's going to be becoming a neurohospitalist, I might focus more on, like the ultimate mental status evaluation, first time seizure, you know, values of an interpretation of CT scans versus MRIs. If they were outpatient, then you're going to be focusing more on the ketic management. So it could be doing some epilepsy or seizure for syncope. You know that's a very common outpatient. So trying to get that subspecialization based on their career goals I think really helps those people leave with the type of fund of knowledge that would be the most valuable for them.

Dr. Michael Kentris: 22:47

No, I think that's great. There's no one size fits all. Certainly, and yeah, I try and do that as well the ebb and flow of the hospital and the clinic sometimes doesn't always lend itself as well as we would like to getting them that direct patient experience. But but I think those are all great points. Um, do you find like, in terms of um, your neurology staff or even the neurology residents? I remember, as a resident myself, we would sometimes go like to our, our psychiatry residency colleagues and we'd do some of their lectures like a lot of times as part of their uh in-service exam prep and we would usually be scheduled uh kind of on a rotating round for different topics and so forth.

Dr. Michael Kentris: 23:33

Um, just curious perspective like resident as teacher versus attending as teacher. Any significant opinions or perspectives?

Dr. Brian Hanrahan: 23:42

Yeah, I mean I think that's a common attribute in all residency programs is to have your own trainees, educators, within the program, as well as trying to have people outside of your residency involved as well. One of the best ways to learn is to teach, is I really do believe that mantra, and it really kind of pushes you to have that fund of knowledge to be able to not only present the information but probably be able to also address follow-up questions as well. For what it's worth, the psychiatry has their own in-service exam equivalent called the PRITE. It's administered in the fall every year. So there are opportunities. I think, because there is a significant overlap between the curriculum of the APPN psychiatry exam and the neurology exam, that there is things that can be addressed in both of those avenues, especially neurocognitive diseases, neurodevelopmental, you know. Even some basic neurology like movement disorders and stroke are going to be seen on your psychiatry Right.

Dr. Michael Kentris: 24:41

You know something, I, something I know again, right in the epilepsy world, I think it's around 80 percent have some sort of comorbid psychiatric diagnosis as well.

Dr. Michael Kentris: 24:51

Um, so it's, you know, a lot of times neurologic and psychiatric disease travel together.

Dr. Michael Kentris: 24:56

And something I had looked up actually in the past is that if you look at the number of psychiatry versus neurology training programs, I think there's something I want to say around 100 or plus more these kinds of programs doing as far as their neurology exposure. They may have private practice neurologists or hospital-employed neurologists, but it's not as integrated or structured per se as what we might see in a place that has both a psychiatry and neurology residency training program and neurology residency training program. And then, just to take that to the you know, further extreme, if you look at the number of internal medicine residency or family medicine residency training programs out there versus right, we're talking, you know, a mismatch of like 10 to 20 to one right. So these places are definitely going to have I, I again right, I'm making some assumptions, but I can only imagine they would have a less structured, uh, educational experience in the neurosciences as compared to a place that has a residency training program in neurology. I don't know, is this something that's ever crossed your mind, or uh, yeah.

Dr. Brian Hanrahan: 26:19

Yeah, I mean, I've always been at a place that had both psychiatry and neurology residency uh programs. You're right in the fact that there's for every one neurology resident there's three psychiatry ones. Um, so it's a much larger uh field of medicine. For I think, for a lot of obvious reasons, um, you know, we do um have our uh. I think the amount of training the psychiatry residents do in neurology is is, um, probably comparable. I think the amount of training the psychiatry residents do in neurology is probably comparable, I think, to the amount of neurology residents do in psychiatry.

Dr. Brian Hanrahan: 26:47

So it's not like a very significant amount of time where you are in that other respective field. So just enough to kind of get a taste. Get a taste. You're right that you'd think that if you're not at a very large, robust academic program where you have both neurology in addition to your psychiatry, the training might suffer. But I mean, that's true, for you can say that same thing in medical school, right? So a lot of DO programs don't require neurology as a core rotation. So a lot of these people are ending up, you know, looking for electives that might not be as academically, you know, versed, but I think you try to find the best opportunities out of that to optimize the learning experience and then kind of grow from there.

Dr. Michael Kentris: 27:35

And you know, as I am a DO graduate and that is exactly my own experience, right you kind of would cold call places and be like, hey, could you take a medical student in February this next year? And sometimes they would say yes, sometimes they would say no, and yeah, it is one of those things. I think it's something like a third of medical schools don't have a neurology clerkship, right? So there is this lack of exposure for many of our colleagues.

Dr. Brian Hanrahan: 28:07

And despite that, you know, over 15% of neurology residents are DO grads. So despite even that additional adversity to overcome, a lot of people are still able to successfully, you know, match into neurology residency still able to successfully, you know, match into neurology residency.

Dr. Michael Kentris: 28:23

Yeah, yeah, and it's. It's very interesting, uh, when I talk with a lot of people in uh, medical education within neurology, we talk about like this, this pipeline from medical school to to residency, um for neurology trainees. And if you look at like the, the match data from last year, I think it was like 94, 95% of programs filled in the match.

Dr. Brian Hanrahan: 28:43

It was 99. There was like one spot out of 878 that didn't match.

Dr. Michael Kentris: 28:47

Right, which is wild right. So I don't know if that's the issue anymore. I think what we're really suffering from is a lack of neurology residencies, like we need more programs to make more spots so we can drive that number down, so then we can worry about the pipeline.

Dr. Brian Hanrahan: 29:06

Yeah, I mean they've been growing the residency. In the same match file I was actually reviewing in preparation for this meeting today, neurology residency programs are growing about like a 2% rate per year. So that's the number of spots. So when you and I were in training we were probably closer to 800. Now we're closer to 900. We might get over 900 in the next year or two, with programs continuing to grow and new ones starting. And yeah, it's nice to see that it's one of the programs, one of the training subspecialties that are so easily filled. Yeah, it means that you know we are definitely a training subspecialty that has as many spots, if not enough, for people that are interested in it. And yeah, and it's something that you have to kind of reflect and look at over time because you know some residency programs are not our residency subspecialties are not seeing that same interest in the field and other ones are growing exponentially larger over time every year compared to us yeah, yeah it's.

Dr. Michael Kentris: 30:14

it's definitely very interesting from that perspective and it does make you wonder um right, because, like we've've those of us again who are kind of in this space there, there've been a few papers over the last five, seven years talking about the projected mismatch of demand versus, like, practicing physicians, and it's only expected to kind of get worse over the next 10 to 20 years.

Dr. Brian Hanrahan: 30:41

For sure. Yeah, it's, it's, you know it looks like. If you look at the data, you know they have that, that graph of you know years, with on the X axis and on the Y axis, the number of positions, and it's growing at the fastest rate it's probably ever have, since they've been keeping track of the data. But there's, they haven't had a match of number of applicants to the number of positions since the 1970s.

Dr. Brian Hanrahan: 31:10

So it would be something that I think they'll never catch up with, because I think everyone wants to be a doctor. So there will always be an interest, and I think there's also a huge you know growth of international applicants too on top of all of that. So, you know, we're not only um accepting people within the us uh, you know medical education system, but a large fraction out of international graduates too right, I think it's, and I apologize, I'm a little vague on some of these.

Dr. Michael Kentris: 31:38

I think it's, and I apologize, I'm a little vague on some of these. I think it's. Around 20 to 30% of practicing neurologists are international medical graduates.

Dr. Brian Hanrahan: 31:46

Yeah, so 204 of the 878 matches this year were international IMGs, and then additional 55 people were US IMGs.

Dr. Michael Kentris: 31:58

Yeah, that's.

Dr. Michael Kentris: 32:00

I mean right, it is one of those things.

Dr. Michael Kentris: 32:03

And something that's very, very interesting to me also is and again, I don't know how familiar you are with it, so again, but the like the visa program in the US for for some of these graduates it's cause, you know, at our program here we'll have, for instance, a lot of IMGs in our internal medicine program, but the hospital, even though we are fairly remote from a lot of bigger cities we're like 50, 60 miles away from Cleveland, pittsburgh, we're kind of in the middle of our own area and we have a very underserved population, both in the urban centers as well as rurally that we don't necessarily fall under the classifications for an at-need designation for some of these visas.

Dr. Michael Kentris: 32:57

And when I hear this, I'm just like you've got to be kidding me Because we don't meet these certain criteria. But you look around with your eyes and you're like we definitely need them, though, and it can definitely be a stumbling block for a lot of people to find jobs after training, and I don't know residents coming through your program. In terms of visa status and things like that down the road, is that something that you kind of have to help them navigate to an extent?

Dr. Brian Hanrahan: 33:20

I'll be honest, I don't have that much experience with it.

Dr. Brian Hanrahan: 33:23

I know it's something that many residency programs take very seriously and in the process of screening people to know what type of visas they would require and if their institution is willing to support those types of visas, and you know, I think the biggest thing that you hit on is the fact that you know, after you're done with your training, you need to be somewhere. I believe in an underserved population and I don't understand the or not that. I don't understand. I just actually don't even know the criteria that need to be met by a hospital system or individual hospital to meet the criteria. But it seems like it's pretty there's not that many in relation to the many of hospitals that are out there. So it is an extremely stressful situation for IMGs in the US educational system to understand, kind of what their next steps are beyond training. You know, and it's a shame that they have to go through that in comparison to US grads which are really kind of having they have a wide open door pretty much beyond that.

Dr. Michael Kentris: 34:26

Yeah, no, I don't pretend to be an expert in this either. It's just something I've run up against when I've had folks where we're trying to recruit right a very small department here and we're kind of cutting out 25% of the pool right out of the door and that obviously is not ideal from a recruitment perspective. So just my own personal frustrations on that one also aspect. You know, kind of looking at the international neurology education front, do you find that in addition to kind of like US-based programs, do you find that you're like now, you know, or other kind of educational things that you've done in the past, are utilized by international training programs?

Dr. Brian Hanrahan: 35:17

Yeah, actually we have had a few institutions reach out for institutional accounts. One of the ones I would mention is there's a program in Jordan that utilizes it. They have a neurology residency program there and has been well received. They renewed their account this past year. I think one of the unique things that are going to be happening over the next decade or so is there's this evolution of something called iACGME programs. Have you heard of that before, mike?

Dr. Michael Kentris: 35:45

I haven't.

Dr. Brian Hanrahan: 35:46

So it's a process actually of like an international ACGME program, training like program like set up so, um, you know, people would be able to be educated internationally and kind of meet the the accreditation criteria for acgb certified programs. Interesting, um, there's not many out there and I think the last time I checked I can't even remember if there's any in neurology, um, but it's a really interesting avenue because there is a lot of limitations in graduates internationally for, you know, future employment in in America because of that um restriction, um, so yeah, we do have some international uh programs.

Dr. Brian Hanrahan: 36:27

Uh, we do have a lot of international people attend our virtual sessions. You know, in in uh January and February every year we host five to six hours of lectures live on Zoom. We then end up eventually getting to our library that all our users can access. But I'd say I think over a third of people are international people looking to learn a little bit and since we have over almost 3,000 followers on Instagram, we have a huge audience. That's well above and beyond you know what a normal or not a normal, but uh, the probably the full volume of graduate medical education trainees in the U?

Dr. Michael Kentris: 37:05

S system? Yeah, Right, it's. It's one of those things where you might feel like you're sitting in your home office or your office at work and you're just talking to a screen, but uh, if there's, you know, a thousand plus people on the other end of that recording right, that fills up a pretty darn big auditorium.

Dr. Brian Hanrahan: 37:22

Yeah, for sure, bigger than the ones I went to.

Dr. Michael Kentris: 37:24

Right, exactly, kind of going back to the IACGME thing. I think that's really interesting because I think we've all known one of our colleagues or one of our trainees who you know. They come from another country, either like in the Midwest or the Middle East sorry, I'm in the Midwest or you know China or Southeast Asia, what have you. And it's like, oh, I was, you know, a surgeon there, or I was a neurologist there, and they have to come back and repeat the training and it just you have to feel bad for, uh, it seems kind of mind boggling.

Dr. Brian Hanrahan: 38:00

Yeah and um, you know I haven't had the opportunity of training alongside many people with that career path but you know you have to really um empathize with that experience and you know I have interviewed, definitely people that have gone through that process themselves and you know that kind of shows you their drive and their willingness to pursue this field of training. You know some medical educators I interact with have always said that you know the international medical, you know trainee cohort are usually some of the hardest working. You know the international medical, you know trainee cohort are usually some of the hardest working. You know trainees they have at their programs. Because of that reason, because they've had to work so incredibly hard to get to where they are They've really, unfortunately, I've had to sacrifice many things to get to where they are in their career that they will do whatever they have to, you know to, you know, become the best doctor that they can be.

Dr. Michael Kentris: 38:58

Right, yeah, if you think about it right, I have to learn new language, move across the world away from family and friends and then work ridiculous hours for, you know, three plus years, depending on your program of specialty of choice, and yeah, and plunk down usually thousands of dollars to do it. Um, yeah, there's a, there's a certain amount of grit that it takes there for sure. Um, as far as kind of people who are looking to get into medical education maybe they're at a smaller institution or they don't have something structured where they are what kind of recommendations do you have? It sounds like you kind of just bootstrapped this thing up, but what kind of suggestions would you have? Or where would people start? If, let's say, we've got a new neurology attending who's kind of out in the middle of nowhere on their own and wants to get involved in medical education, what should they start doing?

Dr. Brian Hanrahan: 39:57

Yeah, that's a great question and I definitely try to find people that are earlier in their careers to try to mentor them. At this point I will say you know, I did have someone like that guiding me early on in my training. So that was Ralph Josefowicz. He was the program director of the University of Rochester for many, many years. He actually was the physician that first published the term neurophobia many years ago. He was a huge person involved in the AAN community. He ran a mind-brain behavior course for the more junior medical students at his institution and I did an acting internship at that program when I was in medical school and he gave a lecture on the career path of a medical educator, which I still have and I still refer to every once in a while, and he broke it down as early training, early career, mid career and late career, and obviously the early career was kind of things that I found most applicable to me at the time and some of the things that were discussed in that included finding a good mentor, looking for opportunities, saying yes to everything, becoming a leader in medical education at your own institution and then, as you got into extended phases of your career, you start to get recognition from a national or even an international range. So that's really what I focused on.

Dr. Brian Hanrahan: 41:20

As a resident, I got an award as a medical student educator of the year and then as a fellow at Rochester I got fellowship educator of the year.

Dr. Brian Hanrahan: 41:31

I got involved with the AAM community in their NeuroReady board prep course, actually as a fellow, the youngest person on that team at the time and then, you know, at other programs regionally close or virtually as well.

Dr. Brian Hanrahan: 42:03

So you know, to summarize, you know look for mentors, look for opportunities and if you're really going to pursue a graduate medical education career whether it's like a clerkship director, fellowship director, fellowship director you really kind of need to start by getting your foot in the door in some way.

Dr. Brian Hanrahan: 42:20

Working in the resident clinic, you know, having trainees rotate with you in clinic giving lectures and then hopefully that would transition to more leadership positions that are not things that are considered core or time.

Dr. Brian Hanrahan: 42:32

So that could be being part of your program evaluation committee which meets, you know, intermittently throughout the year that reviews the curriculum or the training experience of the trainees, the clinical, the CCC, which evaluates resident performance, and giving feedback of what needs to be done if anyone is in risk for remediation or anything along those lines to be done. If anyone is in risk for remediation or anything along those lines, and then as you get more kind of non-protected time leadership positions as other opportunities open up, then you would be the one that would be first considered for those roles. So very often you might get your first foot in the door and then in a few years you might have started getting your first 0.1 or like four hours a week of time towards these more educational roles and then, as you become, if you have the opportunity to become a program director or an assistant program director, that can be significantly more time.

Dr. Michael Kentris: 43:24

No, that's great advice and it is. Yeah, it's one of those things I'm still working out myself where you say yes to everything and at some point you do have to start saying no to things and it's hard to figure out where that point is in your career.

Dr. Brian Hanrahan: 43:39

Yeah, I think you have to also at the very beginning. Right, you say yes to everything because you have nothing. You're not doing anything else.

Dr. Michael Kentris: 43:46

Right.

Dr. Brian Hanrahan: 43:46

But there is definitely a point where you'll be stretching yourself too thin and I've had to say no to a couple opportunities.

Dr. Brian Hanrahan: 43:52

For example, I was for a little while I was involved in the interviewing of medical students for the program I'm at and did a couple of those. But because of the day that they were doing the interviews and having it kind of run in line with our resident interview season, it just wasn't realistic for me to be involved. I wasn't able to really give it my full effort. I wasn't immersed enough to make it an full effort. I wasn't immersed enough to make it an efficient process because I had to kind of relearn the system, the platform and the process every time I did an interview here and there. So by the time you really start saying no, that's kind of when you already have your foot in the door, so to speak, and really trying to be reflective on like, how would this optimize my career path, my career goal of becoming a program director, a clerkship director, or even even, like a shorter step, like an assistant program director, things like that.

Dr. Michael Kentris: 44:48

No, that's great points and yeah, it can be. It can be hard to navigate, especially when you move into those new roles, especially when you're first out of training. But I think you had referenced this earlier.

Dr. Brian Hanrahan: 45:00

It's kind of like finding that mentor, someone who's kind of doing what you're doing or what you you also need to be very focal about what your goal is Right, I think if, if no one knows that that is a career path you're pursuing, they won't consider you or maybe even offer you opportunities to kind of build your educational profile to be considered when that opportunity becomes available so telling your head of your department or the program director that you currently are associated with, or something you know, let me know. I'd love to do whatever I can to be considered for a core faculty position when the next one becomes available. What kind of career path or what steps do you think I would need to complete to get to consideration when that happens?

Dr. Michael Kentris: 45:50

Yeah, no, those are great things. Yeah, I know I've gotten away from from the pure academic employment setting myself, so these are considerations that I have long ago put to the side, unfortunately, but it is. I know there's a lot of folks out there who are in that setting and it's always good because you know everyone's employment situations or work environment can change over time. So it's always good to kind of uh remember these things because it is. It is its own unique animal in terms of like kind of the, the academic hierarchy and structure.

Dr. Brian Hanrahan: 46:38

GME model or leadership, is totally independent of your clinical care model. So knowing kind of who to communicate for certain aspects of your career are important and the turnover is pretty high. The last time I heard, I believe, a program director's average lifespan is about five years, so many of us would be practicing for 30 plus years in their lives. So if they're at the same institution that whole time, there might be five, six times that there's turnover in that leadership. Be practicing for 30 plus years in their lives, so they may, if they're at the same institution that whole time, there might be, you know, five, six times that there's turnover in that leadership position, which provides a lot of opportunities for you know more time and more different roles.

Dr. Michael Kentris: 47:06

Yeah, no, that's a great point. You know they don't want things to get stagnant and it's always good to get fresh blood, fresh perspectives, things like that kind of in there, Although you certainly hear stories about these kind of legendary program directors out there who've done it for 10, 20 years and things like that and did an amazing job the entire time.

Dr. Brian Hanrahan: 47:25

Yeah, I mean those are real people that are really dedicated to that role and are really passionate about their job. Ralph DeCefalo, which is one of them. Deb Bradshaw at University, SUNY, Upstate, was there for many years. Zafar Khan, I believe. He was there for many years at Emory as well, you know. I think Chris Lee at Vanderbilt now has been there for a good amount of time too. So I mean and there's many more that I'm forgetting but you're right that the longer someone usually is in that position, that usually means that they are very, very good at their job and really passionate about it yes, any final thoughts?

Dr. Michael Kentris: 48:03

uh, any advice to those kind of early career, you know, whether they're med students interested in neurology or residents or fellows. Um, I know we've kind of gone through a lot of that stuff already, but like if you had to summarize your best recommendation for people looking to pursue a career in academics or kind of bootstrapping their own academic projects.

Dr. Brian Hanrahan: 48:28

Yeah, I mean, I think, regarding projects and research. I think that's something that a lot of trainees don't have a lot of experience with and they very easily can get guided into a wrong path or a very inefficient path. So whenever I talk with my trainees and they're coming up with study designs or questions, I usually have them answer three questions before we get started. One is do you have a good question, like is this something that people are going to care about, or is this question already been answered? Two, you know, do you have a good study design? So, no matter what, if you have a very good question, if your study design is garbage, no one's going to accept it because it's just not a good study. And three, do you have a realistic timeline? Do you really have the time to see the study through and through? You know, if you're a medical student, you have three more months at your training program before you go into residency. You're not going to write an IRB for a study that takes three years to collect data on right. So you know, if you are able to get those three things identified and I'm satisfied with it you'll get the green light for me to pursue. But you know, mike, I'm sure you have, just like I, have been involved in projects that just went nowhere, and I mean I probably have wasted dozens and dozens, maybe even hundreds of hours of research time into projects that maybe got an abstract at a conference that could have easily been comparable to a case report I wrote in 30 minutes minutes. That is so frustrating, you know, and as a medical student or an early resident, you don't have that insight into what those things are. What's a good study design? What's a good question? What's a realistic timeline? So focusing on those aspects and thinking about how this actually will help you your career path forward is really something really important.

Dr. Brian Hanrahan: 50:14

The Now you Know Neuro Instagram page is something that I follow. I create. I'm the one that probably reviews it almost daily. I'm the one that makes all the memes. For anyone that was curious about that, you know we also, you know, have info at nowyouknownneurocom. If you want to email us about you know, setting up an institutional account, you can find that on our website at nowyouknownurocom.

Dr. Brian Hanrahan: 50:37

For anyone who is interested in psychiatry, we actually launched a sister product called Now you Know Psych for psychiatry residents. They also have a thousand flashcards, chapters, question bank, pretty much everything comparable to, now you Know, neuro for psychiatry residents and we're hoping to grow that over the next year or two. And additionally, we'll be launching, actually an application very soon called, now you Know, med, which is going to be housing our question banks and our flashcard decks for both neurology and psychiatry residency resources. So you know that'll be a mobile app available. You know, in the next couple of weeks, if not a month or two, that I think a lot of lot of our uh subscribers are going to be very excited about, because that's probably one of the only things that kind of um are different from our resources compared to you know more of the some of the better known ones, like uh board vitals and and things like that.

Dr. Michael Kentris: 51:28

Awesome. No, that's great. Um, so again, right, thanks for thank you everyone for listening. So again, thank you everyone for listening. You can, of course, find me on Twitter, slash at Dr Kentris, and then you can always check out theneurotransmitterscom for more information about all of our work. Dr Hanrahan, thank you so much again. I appreciate the talk and I always enjoy getting a fresh perspective on medical education. It's always refreshing to me to talk to someone who's kind of at least, if not more, into this stuff than I am, so I appreciate you taking the time to talk with us today.

Dr. Brian Hanrahan: 52:06

Pleasure of mine, Michael, and great to see kind of this neurotransmitter community grow and develop over time. And I'm sure you've been strategically you're you've been strategically and significantly involved in helping that foster and grow. So I wish you all the best with future growth and development and love to be more involved as things move on.

Dr. Michael Kentris: 52:25

Thank you Appreciate it.