June 20, 2025 • 53 mins
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.
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Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
Dr. Michael Kentris (00:01):
Hello and welcome back to the
Neurotransmitters.
I'm your host, dr MichaelKentris, and today I'm happy to
revisit a subject very near anddear to my heart, and hopefully
to yours as well, which ismedical education in neurology.
And to help me on that journey,today I'm happy to introduce Dr
Brian Hanrahan.
Please let everybody know kindof who you are, what you do.
Dr. Brian Hanrahan (00:25):
All right, michael, thank you very much for
having me.
It's a great honor to be here.
So I am an assistant programdirector of neurology residency,
as well as a fellowshipdirector of clinical
neurophysiology.
I'm board certified inneurology, clinical
neurophysiology and epilepsy.
In addition to those clinicaland medical educational roles,
I'm also co-founder of themedical educational platform.
(00:48):
Now you Know Neuro.
Dr. Michael Kentris (00:50):
Awesome.
So I, as someone who also hasengaged in the online space,
kind of in the medical educationspace, kind of independently to
an extent, I was really happyto hear from you and to kind of
hear about sort of your journeyfrom and we can go back as far
as you want, whether med schoolresidency or wherever you think
(01:12):
it makes sense to kind of pickup the tail and kind of talk
about how you went from kind oftrainee to medical educator.
Dr. Brian Hanrahan (01:19):
Yeah, I love telling this story.
So to be honest, I was alwaysinterested in education.
My mom was an elementary schoolteacher.
I grew up in a family ofeducators.
In the elementary level I wasthe first physician in my family
.
I went to medical school andduring my medical school years I
still really enjoyedinteracting with the clerkship
(01:40):
directors and kind of learninghow medical education was done.
When I got into my neurologyresidency and I was starting to
prepare for the in-serviceexaminations, I just felt there
really wasn't very goodresources available for us to
kind of optimize our knowledgeand time to prepare for these
things.
So after I went to the AANconferences at PGY2 and kind of
(02:03):
just, you know, communicatingwith other leaders in the field,
I kind of realized that thismight be something I need to
kind of tackle myself.
So during my first, you know,pgy2, pgy3 years I started
working on developing sometext-based content for
preparation for the in-serviceand board examinations.
But I really didn't have anidea of how to kind of share
that information in the future.
(02:24):
I figured that would be afuture problem for me.
Fortunately, one of my juniorresidents, steve Gangloff, has a
lot of experience in codecoding and website design.
So I met with him kind of theend of my PGY3 year, beginning
of PGY4, and kind of gave him apitch of what we think we could
put together as an educationalresource for residents and he
(02:46):
was totally on board.
So now that was about longerago than I'd like to admit,
probably about seven or eightyears now.
We had the website launched,probably around 2019.
And then at that time it wasprimarily text-based chapters
and an image database withradiology, eegs, emgs and
(03:08):
pathology.
But since then we really havekind of evolved into having many
more modes of learning,including flashcards.
We now have about a 1300multiple choice question bank
and slowly adding more audiovisual content onto the site as
well.
Dr. Michael Kentris (03:27):
Awesome, yeah, I remember coming across
the website.
Unfortunately, I had been, likeyou said, also longer than I
care to admit, out of residencyfor a couple of years when I saw
it out there and I do thinkback kind of to that landscape.
Right, I took my boards in 2017.
(03:47):
And, as you said, there were ahandful of resources out there
in terms of like.
I was, fortunate enough, one ofmy attendings was Dr Esteban
Ching Ching, who kind of puttogether the for any of the
neurology residents out there,that uh kind of question
comprehensive review inneurology, I think is the title,
(04:07):
uh, which very uh frustratingbook, but also very good as far
as as a textbook is.
And then everything else.
It always seemed like, like youwere saying, all these
different residency programs hadtheir own little pockets of
like things that have beenhanded down generation of
generation to resident buthadn't really been widespread,
(04:31):
and it seems like this is kindof that writ large to an extent.
Dr. Brian Hanrahan (04:36):
Yeah, I mean it's something that has been
grown and fostered frominteracting with residents and
leaders in medical educationacross the country.
I think there's probably been50 to 60 people that have
touched it in some way, whetherit's writing a question,
reviewing a chapter, helping mewith the flashcards, giving
lectures.
So many hands make light workand it's crazy to think kind of
(04:59):
how large and robust it is atthis point.
And I think, mike, you hit agreat point of that.
You know smaller programs,newer programs, don't have that
internal resource available.
You can imagine, you know, whenI became an assistant program
director at my program, we juststarted it so we had to create a
like 200 hour lecture series inthe first year out of scratch.
(05:23):
You know incredibly hard whenyou don't have that.
You know those years ofresearch or old lectures kind of
build on to kind of get to thepoint where you're on the same
tier as well.
Established programs have beenaround for decades, not even
longer.
So this kind of helps programskind of get to that level very
quickly.
And it's great to see how sometraining programs have
(05:45):
incorporated my content intotheir curriculum.
You know whether it's question,review or in some other
modality, because it really.
You know, it's very rewardingto me to kind of see the amount
of influence I've been able tohave in people that I might not
even know personally myself, butit seems to have still some
value.
Dr. Michael Kentris (06:04):
No, that's excellent.
And one of the things I thoughtwas interesting is that you
know you do have on the websitethe option for, like, say, an
institution subscription as well.
And I'm just curious from yourown perspective when, like,
let's say, a residency programsigns up for you know the a year
or a board review series orwhat have you Does like, do they
(06:28):
find that there is an objectiveincrease in either board
passing rates or in terms oftheir in-service exam scores
going up?
Or what kind of metrics do theyreport back to you, or what
kind of feedback do you get fromthe users of your services?
Dr. Brian Hanrahan (06:44):
So subjectively, we get really
great feedback.
The one thing that we've kind oflearned is if we set up an
institutional account or evenlike a free trial for an
institution, you know, in thetime leading into the in-service
exam or just at the beginningof the academic year, the
retention rate is extremely high.
So if people didn't like it orfind it rewarding, they wouldn't
continue to stay with us.
(07:05):
It's a little harder to getthat objective data because I
think you know what metricswould we use.
Necessarily, you know you coulduse board pass rates.
You know, utilizing thein-service exam for something
like this is something I thinkthe AAM would probably not look
kindly upon, probably not lookkindly upon.
(07:25):
They would probably frown uponthat because of you know it's
really a marker of academicperformance and gives you
insight into how your residentsare performing and what you know
deficits they may have thatthey can focus their attention
on before the following year orbefore their boards.
So it's been hard to kind offind that objective data,
although we do have a lot ofsurvey-based insights into the
user experience and it's overallvery positive.
Dr. Michael Kentris (07:46):
Yeah, no, that's a great point.
I do remember as an anxiousfourth-year resident myself,
looking back to see like how youknow, how worried do I need to
be about my in-service examscores versus my likelihood of
passing my boards?
I think I only found like onepaper from like the early 2000s
or 2010s that was looking atthat Like there is an
(08:09):
association.
It was fairly strong, but notsuper robust.
Um, but yeah, it is one ofthose things that, uh, I think
you were absolutely right andyou know we don't need to lean
too much on the in-service examas far as board passing rates
and things like that, becausethat, as you rightly said, is
(08:30):
not the intent of the test.
It's not there to be apunishment or a scourge for
those who didn't perform well.
Hopefully more encouragement.
Dr. Brian Hanrahan (08:40):
Yeah, many PGY-2s come in thinking it's
something as serious as like ashelf exam in medical school or
something like that, and we kindof have to reassure them that
no, that's not how this works.
This is really just a marker.
You know, only the academicleadership at your institution
should know your performance andif anyone asks in your
interview season, you've got tolet us know, because they, you
know, we actually.
You know, I think the AAMencourages you to report that
(09:01):
type of behavior.
Yeah, another encourages you toreport that type of behavior.
Yeah, another thing to build onthat Mike, you mentioned that
research article.
You're right, that waspublished by the AAN.
I don't remember the exactnumbers off my head, but I think
there was like a 99 pass rate.
If your score was like 65% orhigher, yeah, so 65% of the
question is correct, right.
So that's pretty dated and theright exam has had some
(09:25):
dramatically dramaticimprovements in the curriculum,
the question content, the imagecontent, is now online based or,
I guess, electronic instead ofpaper based with a pen and
pencil, like you and I remembertaking it like and squinting and
couldn't see the pixelated grayfigures.
So they've done a great jobimproving that exam and they've
(09:48):
made a lot of changes to reflectsome of the blueprint for the
ADP exam.
So at the AAN conference thisApril they announced that
they're going to do anotherreview of the performance on the
NSERF exam in relation toboards and hopefully that should
be coming out in the next yearor so.
So I'm really curious to seewhat the new data is.
(10:09):
Because the exam is now sodramatically different.
Because that's really somethingthat I need to know as a medical
educator when I'm, you know,communicating with my trainees,
because realistically I kind ofwant to know what is the
threshold for my graduatingclass to perform at, for me to
say you have nothing to worryabout, or to put someone on
alert and say, listen, youreally need to buckle down and
(10:30):
spend a lot more time learningand paying attention and
focusing on these aspects.
They do give you that kind ofdetailed breakdown of not only
what subjects people struggledin but also what topics whether
it's an easy, medium, hard theystruggled in and also like at an
institutional level too.
So I think that's really greatas a medical educator to review
(10:51):
all that information to kind of,you know, potentially make some
modifications to yourcurriculum in any individual
year If you know that yourschool struggled in you know
neuroinfectious diseases, thatmight be something you want to
add one or two lectures on.
You know in neuroinfectiousdiseases that might be something
you want to add one or twolectures on.
Dr. Michael Kentri (11:06):
Incorporated throughout the academic year.
No, that's great, and I doremember anecdotally my own
scores and I like to think thatthey're fairly representative of
most junior residents back then, which would have been like
neuro-oncology pediatricneurology which would have been
like like neuro-oncology,pediatric neurology, yeah, um,
(11:31):
and then a lot of times,especially as a PGY2, like a lot
of the pathology, likeneuropath questions.
Uh, those are always one of thethings that are just like ripe
for questions.
Yeah, and I, I remember, as yousaid, it's it's someone who's a
little bit away from that nowand not working directly with
neurology residents as often.
Who's a little bit away fromthat now and not working
directly with neurologyresidents as often um, there was
.
There was always a lot ofcomplaining when the right uh
right exam time came around,because there's like such a
(11:53):
disconnect in terms of what theywere asking you versus what you
are likely to be seeing on yourboard exams that it was felt
you know, to use some extremelanguage like a waste of time.
Uh, uh, to an extent, whichprobably a bit of an
over-exaggeration, but we allknow how, how you can be when
you're in residency and tiredand frustrated, um, but yeah any
(12:14):
core, any core faculty memberin medical education, in
neurology are going to hear thatafter the exam like, oh, they
asked these mundane, intricatelittle questions.
Dr. Brian Hanrahan (12:23):
Um, but you know I always kind of explain.
There's, you know, there'sclinical fund of knowledge, like
practice practicing fund ofknowledge, and textbook or board
exam fund of knowledge.
And yes, there's significantoverlap but there's a little bit
on each side of those that arenot going to be applicable to
both and you just have to beaware of that and really focus
your time when you are learningindependently on those kinds of
(12:46):
things that are outside thatVenn diagram.
I think one of the biggestcriticisms you could have about
the in-service exam as an adultneurology resident is that they
do have a lot of pediatrics anda higher percentage of pediatric
neurology on it compared towhat you're going to be taking
on the adult neurology boardexam, and it's because it's
created to be taken by bothpediatric and adult neurology
(13:09):
residents.
There are some discussionsagain in April this year of
possibly separating out thepediatric and the adult
neurology residency and serviceexaminations, which I actually
think would be a great idea,because then you'd be able to
have the exam more reflective ofwhat those future trainees are
going to take and with, I think,the team that they had in the
(13:30):
AA, and I think they definitelywould be able to create, um, you
know, a question bank thatwould 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 similardiscourse as well, uh, from some
of our child neurologycolleagues.
I've heard similar discourse aswell from some of our child
neurology colleagues, and, yeah,it is one of these things where
we see this continued I hate touse the word balkanization like
even within neurology, adultneurology, and there's just such
(14:03):
a vastness of information thatit does become almost
challenging to say, like, whatshould a graduating general
neurologist know?
And that's, I think, becoming aharder question to answer at
times.
I'm curious what yourperspective is as someone in
kind of more involved intraining residents at present.
Dr. Brian Hanrahan (14:19):
Yeah.
So it is definitely gettingharder, I think, to figure out
what esoteric information isreally needed, and I think both
you and me, Mike, now we've beenaround long enough, as much as
we wouldn't like to admit tohave seen that kind of evolve
over time.
Because I think historicallythere was a lot more neuropath
(14:39):
evaluated, a lot more of thebiochemistry, isosomal storage,
diseases, things like that thatare being incorporated, but now
things are just a little biteasier to do.
I think the role of aneurologist has evolved over
time too, and I think one of thehard things too is just the
evolving range ofneuropharmacology available.
(15:01):
If you think about just likeall the MS therapies that have
been approved in the last fiveyears, it's overwhelming.
And how much of all of that doesa neurology resident need to
know, being that they might notreally be practicing that aspect
in great detail?
I think that's a big strugglethat a lot of question exam
(15:24):
companies struggle with, becausewhen you are at creating, you
know questions or teachingpoints that are really
(15:48):
reflective of what afoundational trainee would need
to know.
So there's always that constantbattle.
So when we have like peoplecontribute to now you know neuro
, I actually usually like tohave people that are more in the
higher tiers of their graduatemedical education or just out of
training or in residence or infellowship, because they kind of
(16:09):
have a better idea of what thatfoundational knowledge is, as
opposed to like that super subspecialized components.
Dr. Michael Kentris (16:15):
No, that's a that's a great point.
It kind of puts me in mind ofsome of that YouTube video
series where you know, like aphysicist explains black holes
at five different levels.
You know down to, like a kid ina garden, or up to another
another PhD.
Yeah, Like you said.
(16:37):
It's exactly what you said.
You get these deep, deep, likethey're at the cutting, bleeding
edge of research and you getall this minutiae of these drugs
coming down the pipeline and wethink they get really
mechanistic and maybe thegeneral neurologist out there
just needs to know do I need tocheck liver enzymes periodically
(16:58):
on this medication, or what'sup?
Dr. Brian Hanrahan (17:01):
When do I refer to a specialist?
yes, exactly when do I submitthem into the epilepsy
monitoring unit, things likethat, right, yeah, and I?
That's that ability tocommunicate at.
You know, what I argue is likean eighth grade reading level is
really also can be um valuablein patient care, right?
One thing I've also haveexperienced when I work with
(17:22):
newly graduated medical studentsin residency is that they have
this huge fund of knowledge theywant to show off right, because
they've worked very hard to getto where they are.
And then when they'recommunicating things to their
patients, sometimes it's at ahigh level where you would need
to have that graduate degree tofully comprehend the whole
conversation level where youwould need to have that graduate
(17:43):
degree to fully comprehend thewhole conversation.
But being able to communicatethat in a very easy way or
really understandable way wouldbe something that your patients
are really going to appreciate,right, because then they
actually have understanding oftheir own health.
Dr. Michael Kentris (17:55):
Yeah, I know I was guilty of this the
other day because I always askthe patients when I'm explaining
something how much do you wantto know, right?
So I was talking aboutfunctional neurologic disorders
with someone and they wanted toknow more.
So I was like, so we talkedabout the interoceptive network
for a few minutes, which I youknow, to be honest.
(18:17):
Right, it's one of those thingsthat, again, right, we don't
necessarily learn as much inresidency, but you and I, we
both did epilepsy fellowship andit's something we see all the
time.
So I have this book now on myshelf where I kind of go back.
I got the clinical foundation,now I can go back and dive into
(18:40):
some of the neuroscience.
I got the clinical foundation.
Now I can go back and dive intosome of the neuroscience
instead of being a pretendneuroscientist, try and get some
of the actual foundationalinformation there and read more
about some of these things thatI hear these researchers talking
about.
So I have some foundationalunderstanding and hopefully I
can use that information that Iaccrue to explain it in a more
(19:00):
clear and concise manner, asopposed to, like you know, like
uh, for those who are familiarlike the common analogy uses,
like the software hardwaremismatch um, which, you know,
not entirely accurate, right,like most analogies, it breaks
down at some point, but butright.
The more we know, the morecreative we can be in terms of
our descriptions and hopefullycommunicate things more
(19:25):
accurately, kind of meeting thepatient 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 whattheir, their understanding is of
that diagnosis to begin with,right to begin with right.
Especially again in that realmof conversion disorder or
non-epileptic events, there issuch a stigmatization of that.
They may have been told thatthey're crazy, that they're
doing some purpose.
It's all in their head, likeall these kind of huge things
(19:51):
that are obviously nothing thatany trained epileptologist would
ever say in a patient room.
It really kind of helps you getit up, preps you for that type
of conversation and seeing howmuch empathy you know is needed
to kind of convey some of theseteaching points or these
educational points for thepatient.
Dr. Michael Kentris (20:09):
Absolutely.
Now, one thing I'm curious tohear your perspective on is, you
know so I was at a neurologyresidency for my first few years
out of training and I moved andI'm currently at a community
teaching hospital.
So most of my educational roleis dealing with non-neurology
residents, so internal medicine,family medicine, emergency
(20:30):
medicine and so kind of thesefrontline primary care
physicians or physicians to be.
Well, no, they're physicians,they're soon to be independent,
and so getting them acclimatedwith common neurologic disorders
that you know, I try and do mybest to identify, like, what are
the most important things thatthey need to know, if they're,
(20:52):
you know, because there's plentyof neurology deserts throughout
the country, you know, letalone throughout the world.
So how can we get these primarycare physicians to kind of get
the essentials down so that theycan hopefully manage some of
the more common disorders outthere?
And I'm curious, like insomeone who is in a more
structured teaching role, how doyou find that integrates into,
(21:15):
kind of the overall structure ofthe neurology residency program
?
Dr. Brian Hanrahan (21:20):
Yeah, I mean we have.
I think every neurologyresidency program would probably
still have trainees rotating ontheir services that are outside
neurology, right, you know, ifpsychiatry has to do neurology
exposures, internal medicinewill come through.
If you have neurosurgery, youknow they may be rotating in
your vascular neurology or inservice services.
And I think it's reallyimportant that you have some
(21:41):
personalization based on youknow the type of training that
person has and also how muchtime you have with them.
Right, you know if you onlyhave, like you know, a week with
them, you know how much arethey going to get out of that.
You're kind of limited andyou're not going to cover all
the bases, but whenever I dowork with anyone outside of my
residency program, I kind ofalways want to know what their
(22:03):
future goals are regarding theircareer, like what career path
they're going into.
So then I can kind of modify myeducational teaching points
based on those components.
Right, if someone's going to bebecoming a neurohospitalist, I
might focus more on, like theultimate mental status
evaluation, first time seizure,you know, values of an
interpretation of CT scansversus MRIs.
(22:25):
If they were outpatient, thenyou're going to be focusing more
on the ketic management.
So it could be doing someepilepsy or seizure for syncope.
You know that's a very commonoutpatient.
So trying to get thatsubspecialization based on their
career goals I think reallyhelps those people leave with
the type of fund of knowledgethat would be the most valuable
(22:46):
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 anddo that as well the ebb and flow
of the hospital and the clinicsometimes doesn't always lend
itself as well as we would liketo getting them that direct
patient experience.
But but I think those are allgreat points.
Um, do you find like, in termsof um, your neurology staff or
(23:14):
even the neurology residents?
I remember, as a residentmyself, we would sometimes go
like to our, our psychiatryresidency colleagues and we'd do
some of their lectures like alot of times as part of their uh
in-service exam prep and wewould usually be scheduled uh
kind of on a rotating round fordifferent topics and so forth.
Um, just curious perspectivelike resident as teacher versus
(23:37):
attending as teacher.
Any significant opinions orperspectives?
Dr. Brian Hanrahan (23:42):
Yeah, I mean I think that's a common
attribute in all residencyprograms is to have your own
trainees, educators, within theprogram, as well as trying to
have people outside of yourresidency involved as well.
One of the best ways to learnis to teach, is I really do
believe that mantra, and itreally kind of pushes you to
have that fund of knowledge tobe able to not only present the
(24:05):
information but probably be ableto also address follow-up
questions as well.
For what it's worth, thepsychiatry has their own
in-service exam equivalentcalled the PRITE.
It's administered in the fallevery year.
So there are opportunities.
I think, because there is asignificant overlap between the
curriculum of the APPNpsychiatry exam and the
(24:26):
neurology exam, that there isthings that can be addressed in
both of those avenues,especially neurocognitive
diseases, neurodevelopmental,you know.
Even some basic neurology likemovement disorders and stroke
are going to be seen on yourpsychiatry Right.
Dr. Michael Kentris (24:41):
You know something, I, something I know
again, right in the epilepsyworld, I think it's around 80
percent have some sort ofcomorbid psychiatric diagnosis
as well.
Um, so it's, you know, a lot oftimes neurologic and psychiatric
disease travel together.
And something I had looked upactually in the past is that if
(25:01):
you look at the number ofpsychiatry versus neurology
training programs, I thinkthere's something I want to say
around 100 or plus more thesekinds of programs doing as far
as their neurology exposure.
They may have private practiceneurologists or
(25:28):
hospital-employed neurologists,but it's not as integrated or
structured per se as what wemight see in a place that has
both a psychiatry and neurologyresidency training program and
neurology residency trainingprogram.
And then, just to take that tothe you know, further extreme,
if you look at the number ofinternal medicine residency or
(25:48):
family medicine residencytraining programs out there
versus right, we're talking, youknow, a mismatch of like 10 to
20 to one right.
So these places are definitelygoing to have I, I again right,
I'm making some assumptions, butI can only imagine they would
have a less structured, uh,educational experience in the
neurosciences as compared to aplace that has a residency
(26:11):
training program in neurology.
I don't know, is this somethingthat'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 andneurology residency uh programs.
You're right in the fact thatthere's for every one neurology
resident there's threepsychiatry ones.
Um, so it's a much larger uhfield of medicine.
For I think, for a lot ofobvious reasons, um, you know,
we do um have our uh.
I think the amount of trainingthe psychiatry residents do in
(26:40):
neurology is is, um, probablycomparable.
I think the amount of trainingthe psychiatry residents do in
neurology is probably comparable, I think, to the amount of
neurology residents do inpsychiatry.
So it's not like a verysignificant amount of time where
you are in that otherrespective field.
So just enough to kind of get ataste.
Get a taste.
(27:03):
You're right that you'd thinkthat if you're not at a very
large, robust academic programwhere you have both neurology in
addition to your psychiatry,the training might suffer.
But I mean, that's true, foryou can say that same thing in
medical school, right?
So a lot of DO programs don'trequire neurology as a core
rotation.
So a lot of these people areending up, you know, looking for
electives that might not be asacademically, you know, versed,
(27:28):
but I think you try to find thebest opportunities out of that
to optimize the learningexperience 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 ownexperience, right you kind of
would cold call places and belike, hey, could you take a
medical student in February thisnext year?
And sometimes they would sayyes, sometimes they would say no
, and yeah, it is one of thosethings.
(27:55):
I think it's something like athird of medical schools don't
have a neurology clerkship,right?
So there is this lack ofexposure 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 additionaladversity to overcome, a lot of
people are still able tosuccessfully, you know, match
into neurology residency stillable to successfully, you know,
match into neurology residency.
Dr. Michael Kentris (28:23):
Yeah, yeah, and it's.
It's very interesting, uh, whenI talk with a lot of people in
uh, medical education withinneurology, we talk about like
this, this pipeline from medicalschool 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% ofprograms filled in the match.
Dr. Brian Hanrahan (28:43):
It was 99.
There was like one spot out of878 that didn't match.
Dr. Michael Kentris (28:47):
Right, which is wild right.
So I don't know if that's theissue anymore.
I think what we're reallysuffering from is a lack of
neurology residencies, like weneed more programs to make more
spots so we can drive thatnumber 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 wasactually reviewing in
preparation for this meetingtoday, neurology residency
programs are growing about likea 2% rate per year.
So that's the number of spots.
So when you and I were intraining we were probably closer
to 800.
Now we're closer to 900.
(29:27):
We might get over 900 in thenext year or two, with programs
continuing to grow and new onesstarting.
And yeah, it's nice to see thatit's one of the programs, one
of the training subspecialtiesthat are so easily filled.
Yeah, it means that you know weare definitely a training
(29:50):
subspecialty that has as manyspots, if not enough, for people
that are interested in it.
And yeah, and it's somethingthat you have to kind of reflect
and look at over time becauseyou know some residency programs
are not our residencysubspecialties are not seeing
that same interest in the fieldand other ones are growing
exponentially larger over timeevery year compared to us yeah,
(30:13):
yeah it's.
Dr. Michael Kentris (30:14):
it's definitely very interesting from
that perspective and it doesmake you wonder um right,
because, like we've've those ofus again who are kind of in this
space there, there've been afew papers over the last five,
seven years talking about theprojected mismatch of demand
versus, like, practicingphysicians, and it's only
(30:37):
expected to kind of get worseover the next 10 to 20 years.
Dr. Brian Hanrahan (30:41):
For sure.
Yeah, it's, it's, you know itlooks like.
If you look at the data, youknow they have that, that graph
of you know years, with on the Xaxis and on the Y axis, the
number of positions, and it'sgrowing at the fastest rate it's
probably ever have, sincethey've been keeping track of
the data.
But there's, they haven't had amatch of number of applicants
(31:03):
to the number of positions sincethe 1970s.
So it would be something that Ithink they'll never catch up
with, because I think everyonewants to be a doctor.
So there will always be aninterest, and I think there's
also a huge you know growth ofinternational applicants too on
(31:24):
top of all of that.
So, you know, we're not only umaccepting people within the us
uh, you know medical educationsystem, but a large fraction out
of international graduates tooright, I think it's, and I
apologize, I'm a little vague onsome 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 practicingneurologists are international
medical graduates.
Dr. Brian Hanrahan (31:46):
Yeah, so 204 of the 878 matches this year
were international IMGs, andthen additional 55 people were
US IMGs.
Dr. Michael Kentris (31:58):
Yeah, that's.
I mean right, it is one of thosethings.
And something that's very, veryinteresting to me also is and
again, I don't know how familiaryou are with it, so again, but
the like the visa program in theUS for for some of these
graduates it's cause, you know,at our program here we'll have,
for instance, a lot of IMGs inour internal medicine program,
(32:23):
but the hospital, even though weare fairly remote from a lot of
bigger cities we're like 50, 60miles away from Cleveland,
pittsburgh, we're kind of in themiddle of our own area and we
(32:51):
have a very underservedpopulation, both in the urban
centers as well as rurally thatwe don't necessarily fall under
the classifications for anat-need designation for some of
these visas.
And when I hear this, I'm justlike you've got to be kidding me
Because we don't meet thesecertain criteria.
But you look around with youreyes and you're like we
definitely need them, though,and it can definitely be a
stumbling block for a lot ofpeople to find jobs after
(33:12):
training, and I don't knowresidents coming through your
program.
In terms of visa status andthings like that down the road,
is that something that you kindof 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.
I know it's something that manyresidency programs take very
seriously and in the process ofscreening people to know what
type of visas they would requireand if their institution is
willing to support those typesof visas, and you know, I think
the biggest thing that you hiton is the fact that you know,
(33:42):
after you're done with yourtraining, you need to be
somewhere.
I believe in an underservedpopulation and I don't
understand the or not that.
I don't understand.
I just actually don't even knowthe criteria that need to be
met by a hospital system orindividual hospital to meet the
criteria.
But it seems like it's prettythere's not that many in
(34:02):
relation to the many ofhospitals that are out there.
So it is an extremely stressfulsituation 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 thatthey have to go through that in
comparison to US grads whichare really kind of having they
have a wide open door prettymuch 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 upagainst when I've had folks
where we're trying to recruitright a very small department
here and we're kind of cuttingout 25% of the pool right out of
the door and that obviously isnot ideal from a recruitment
perspective.
(34:46):
So just my own personalfrustrations on that one also
aspect.
You know, kind of looking atthe international neurology
education front, do you findthat in addition to kind of like
(35:07):
US-based programs, do you findthat you're like now, you know,
or other kind of educationalthings that you've done in the
past, are utilized byinternational training programs?
Dr. Brian Hanrahan (35:17):
Yeah, actually we have had a few
institutions reach out forinstitutional accounts.
One of the ones I would mentionis there's a program in Jordan
that utilizes it.
They have a neurology residencyprogram there and has been well
received.
They renewed their account thispast year.
I think one of the uniquethings that are going to be
(35:38):
happening over the next decadeor so is there's this evolution
of something called iACGMEprograms.
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, peoplewould be able to be educated
internationally and kind of meetthe the accreditation criteria
for acgb certified programs.
Interesting, um, there's notmany out there and I think the
(36:07):
last time I checked I can't evenremember if there's any in
neurology, um, but it's a reallyinteresting avenue because
there is a lot of limitations ingraduates internationally for,
you know, future employment inin America because of that um
restriction, um, so yeah, we dohave some international uh
programs.
Uh, we do have a lot ofinternational people attend our
(36:29):
virtual sessions.
You know, in in uh January andFebruary every year we host five
to six hours of lectures liveon Zoom.
We then end up eventuallygetting to our library that all
our users can access.
But I'd say I think over athird of people are
international people looking tolearn a little bit and since we
have over almost 3,000 followerson Instagram, we have a huge
(36:53):
audience.
That's well above and beyondyou know what a normal or not a
normal, but uh, the probably thefull 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 whereyou might feel like you're
sitting in your home office oryour office at work and you're
just talking to a screen, but uh, if there's, you know, a
thousand plus people on theother end of that recording
right, that fills up a prettydarn 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 reallyinteresting because I think
we've all known one of ourcolleagues 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 inthe Midwest or you know China or
(37:45):
Southeast Asia, what have you.
And it's like, oh, I was, youknow, a surgeon there, or I was
a neurologist there, and theyhave to come back and repeat the
training and it just you haveto 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 trainingalongside many people with that
career path but you know youhave to really um empathize with
that experience and you know Ihave interviewed, definitely
people that have gone throughthat process themselves and you
know that kind of shows youtheir drive and their
(38:23):
willingness to pursue this fieldof training.
You know some medical educatorsI interact with have always
said that you know theinternational medical, you know
trainee cohort are usually someof the hardest working.
You know the internationalmedical, you know trainee cohort
are usually some of the hardestworking.
You know trainees they have attheir programs.
Because of that reason, becausethey've had to work so
incredibly hard to get to wherethey are They've really,
(38:47):
unfortunately, I've had tosacrifice many things to get to
where they are in their careerthat 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 workridiculous hours for, you know,
three plus years, depending onyour program of specialty of
choice, and yeah, and plunk downusually thousands of dollars to
do it.
Um, yeah, there's a, there's acertain amount of grit that it
(39:19):
takes there for sure.
Um, as far as kind of peoplewho are looking to get into
medical education maybe they'reat a smaller institution or they
don't have something structuredwhere they are what kind of
recommendations do you have?
It sounds like you kind of justbootstrapped this thing up, but
(39:42):
what kind of suggestions wouldyou have?
Or where would people start?
If, let's say, we've got a newneurology attending who's kind
of out in the middle of nowhereon 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 peoplethat are earlier in their
careers to try to mentor them.
At this point I will say youknow, I did have someone like
that guiding me early on in mytraining.
So that was Ralph Josefowicz.
He was the program director ofthe University of Rochester for
many, many years.
He actually was the physicianthat first published the term
(40:18):
neurophobia many years ago.
He was a huge person involvedin the AAN community.
He ran a mind-brain behaviorcourse for the more junior
medical students at hisinstitution and I did an acting
internship at that program whenI was in medical school and he
gave a lecture on the careerpath of a medical educator,
(40:40):
which I still have and I stillrefer to every once in a while,
and he broke it down as earlytraining, early career, mid
career and late career, andobviously the early career was
kind of things that I found mostapplicable to me at the time
and some of the things that werediscussed in that included
finding a good mentor, lookingfor opportunities, saying yes to
(41:02):
everything, becoming a leaderin medical education at your own
institution and then, as yougot into extended phases of your
career, you start to getrecognition from a national or
even an international range.
So that's really what I focusedon.
As a resident, I got an award asa medical student educator of
(41:25):
the year and then as a fellow atRochester I got fellowship
educator of the year.
I got involved with the AAMcommunity in their NeuroReady
board prep course, actually as afellow, the youngest person on
that team at the time and then,you know, at other programs
(41:59):
regionally close or virtually aswell.
So you know, to summarize, youknow look for mentors, look for
opportunities and if you'rereally going to pursue a
graduate medical educationcareer whether it's like a
clerkship director, fellowshipdirector, fellowship director
you really kind of need to startby getting your foot in the
door in some way.
(42:20):
Working in the resident clinic,you know, having trainees rotate
with you in clinic givinglectures and then hopefully that
would transition to moreleadership positions that are
not things that are consideredcore or time.
So that could be being part ofyour program evaluation
committee which meets, you know,intermittently throughout the
year that reviews the curriculumor the training experience of
the trainees, the clinical, theCCC, which evaluates resident
(42:48):
performance, and giving feedbackof what needs to be done if
anyone is in risk forremediation or anything along
those lines to be done.
If anyone is in risk forremediation or anything along
those lines, and then as you getmore kind of non-protected time
leadership positions as otheropportunities open up, then you
would be the one that would befirst considered for those roles
.
So very often you might getyour first foot in the door and
(43:10):
then in a few years you mighthave started getting your first
0.1 or like four hours a week oftime towards these more
educational roles and then, asyou become, if you have the
opportunity to become a programdirector or an assistant program
director, that can besignificantly more time.
Dr. Michael Kentris (43:24):
No, that's great advice and it is.
Yeah, it's one of those thingsI'm still working out myself
where you say yes to everythingand at some point you do have to
start saying no to things andit'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 toeverything 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 thinand I've had to say no to a
couple opportunities.
For example, I was for a littlewhile I was involved in the
interviewing of medical studentsfor the program I'm at and did
a couple of those.
But because of the day thatthey were doing the interviews
and having it kind of run inline with our resident interview
(44:08):
season, it just wasn'trealistic for me to be involved.
I wasn't able to really give itmy full effort.
I wasn't immersed enough tomake it an full effort.
I wasn't immersed enough tomake it an efficient process
because I had to kind of relearnthe system, the platform and
the process every time I did aninterview here and there.
So by the time you really startsaying no, that's kind of when
(44:31):
you already have your foot inthe door, so to speak, and
really trying to be reflectiveon like, how would this optimize
my career path, my career goalof becoming a program director,
a clerkship director, or eveneven, 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 whenyou're first out of training.
But I think you had referencedthis earlier.
Dr. Brian Hanrahan (45:00):
It's kind of like finding that mentor,
someone who's kind of doing whatyou're doing or what you you
also need to be very focal aboutwhat your goal is Right, I
think if, if no one knows thatthat is a career path you're
pursuing, they won't consideryou or maybe even offer you
(45:22):
opportunities to kind of buildyour educational profile to be
considered when that opportunitybecomes available so telling
your head of your department orthe program director that you
currently are associated with,or something you know, let me
know.
I'd love to do whatever I canto be considered for a core
(45:44):
faculty position when the nextone becomes available.
What kind of career path orwhat steps do you think I would
need to complete to get toconsideration when that happens?
Dr. Michael Kentris (45:50):
Yeah, no, those are great things.
Yeah, I know I've gotten awayfrom from the pure academic
employment setting myself, sothese are considerations that I
have long ago put to the side,unfortunately, but it is.
I know there's a lot of folksout there who are in that
setting and it's always goodbecause you know everyone's
(46:14):
employment situations or workenvironment can change over time
.
So it's always good to kind ofuh remember these things because
it is.
It is its own unique animal interms of like kind of the, the
academic hierarchy and structure.
Dr. Brian Hanrahan (46:38):
GME model or leadership, is totally
independent of your clinicalcare model.
So knowing kind of who tocommunicate for certain aspects
of your career are important andthe turnover is pretty high.
The last time I heard, Ibelieve, a program director's
average lifespan is about fiveyears, so many of us would be
practicing for 30 plus years intheir lives.
So if they're at the sameinstitution that whole time,
there might be five, six timesthat there's turnover in that
leadership.
Be practicing for 30 plus yearsin their lives, so they may, if
they're at the same institutionthat whole time, there might be
, you know, five, six times thatthere's turnover in that
(47:00):
leadership position, whichprovides a lot of opportunities
for you know more time and moredifferent roles.
Dr. Michael Kentris (47:06):
Yeah, no, that's a great point.
You know they don't want thingsto get stagnant and it's always
good to get fresh blood, freshperspectives, things like that
kind of in there, Although youcertainly hear stories about
these kind of legendary programdirectors out there who've done
it for 10, 20 years and thingslike 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 roleand are really passionate about
their job.
Ralph DeCefalo, which is one ofthem.
Deb Bradshaw at University,SUNY, Upstate, was there for
many years.
Zafar Khan, I believe.
He was there for many years atEmory as well, you know.
I think Chris Lee at Vanderbiltnow has been there for a good
(47:46):
amount of time too.
So I mean and there's many morethat I'm forgetting but you're
right that the longer someoneusually is in that position,
that usually means that they arevery, very good at their job
and really passionate about ityes, any final thoughts?
Dr. Michael Kentris (48:03):
uh, any advice to those kind of early
career, you know, whetherthey're med students interested
in neurology or residents orfellows.
Um, I know we've kind of gonethrough a lot of that stuff
already, but like if you had tosummarize your best
recommendation for peoplelooking to pursue a career in
academics or kind ofbootstrapping their own academic
(48:26):
projects.
Dr. Brian Hanrahan (48:28):
Yeah, I mean , I think, regarding projects
and research.
I think that's something that alot of trainees don't have a
lot of experience with and theyvery easily can get guided into
a wrong path or a veryinefficient path.
So whenever I talk with mytrainees and they're coming up
with study designs or questions,I usually have them answer
(48:49):
three questions before we getstarted.
One is do you have a goodquestion, like is this something
that people are going to careabout, or is this question
already been answered?
Two, you know, do you have agood study design?
So, no matter what, if you havea very good question, if your
study design is garbage, noone's going to accept it because
it's just not a good study.
And three, do you have arealistic timeline?
Do you really have the time tosee the study through and
(49:10):
through?
You know, if you're a medicalstudent, you have three more
months at your training programbefore you go into residency.
You're not going to write anIRB for a study that takes three
years to collect data on right.
So you know, if you are able toget those three things
identified and I'm satisfiedwith it you'll get the green
light for me to pursue.
But you know, mike, I'm sureyou have, just like I, have been
(49:34):
involved in projects that justwent nowhere, and I mean I
probably have wasted dozens anddozens, maybe even hundreds of
hours of research time intoprojects that maybe got an
abstract at a conference thatcould have easily been
comparable to a case report Iwrote in 30 minutes minutes.
(49:57):
That is so frustrating, youknow, and as a medical student
or an early resident, you don'thave 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 aspectsand thinking about how this
actually will help you yourcareer path forward is really
something really important.
The Now you Know Neuro Instagrampage is something that I follow
.
I create.
(50:18):
I'm the one that probablyreviews it almost daily.
I'm the one that makes all thememes.
For anyone that was curiousabout that, you know we also,
you know, have info atnowyouknownneurocom.
If you want to email us aboutyou know, setting up an
institutional account, you canfind that on our website at
nowyouknownurocom.
For anyone who is interested inpsychiatry, we actually launched
(50:40):
a sister product called Now youKnow Psych for psychiatry
residents.
They also have a thousandflashcards, chapters, question
bank, pretty much everythingcomparable to, now you Know,
neuro for psychiatry residentsand we're hoping to grow that
over the next year or two.
And additionally, we'll belaunching, actually an
application very soon called,now you Know, med, which is
(51:05):
going to be housing our questionbanks and our flashcard decks
for both neurology andpsychiatry residency resources.
So you know that'll be a mobileapp available.
You know, in the next couple ofweeks, if not a month or two,
that I think a lot of lot of ouruh subscribers are going to be
very excited about, becausethat's probably one of the only
things that kind of um aredifferent from our resources
compared to you know more of thesome of the better known ones,
like uh board vitals and andthings like that.
Dr. Michael Kentris (51:28):
Awesome.
No, that's great.
Um, so again, right, thanks forthank you everyone for
listening.
So again, thank you everyonefor listening.
You can, of course, find me onTwitter, slash at Dr Kentris,
and then you can always checkout theneurotransmitterscom for
more information about all ofour work.
Dr Hanrahan, thank you so muchagain.
(51:49):
I appreciate the talk and Ialways enjoy getting a fresh
perspective on medical education.
It's always refreshing to me totalk to someone who's kind of
at least, if not more, into thisstuff than I am, so I
appreciate you taking the timeto talk with us today.
Dr. Brian Hanrahan (52:06):
Pleasure of mine, Michael, and great to see
kind of this neurotransmittercommunity grow and develop over
time.
And I'm sure you've beenstrategically you're you've been
strategically and significantlyinvolved in helping that foster
and grow.
So I wish you all the best withfuture growth and development
and love to be more involved asthings move on.
Dr. Michael Kentris (52:25):
Thank you Appreciate it.
Hello and welcome back to the
Neurotransmitters.
I'm your host, dr MichaelKentris, and today I'm happy to
revisit a subject very near anddear to my heart, and hopefully
to yours as well, which ismedical education in neurology.
And to help me on that journey,today I'm happy to introduce Dr
Brian Hanrahan.
Please let everybody know kindof who you are, what you do.
Dr. Brian Hanrahan (00:25):
All right, michael, thank you very much for
having me.
It's a great honor to be here.
So I am an assistant programdirector of neurology residency,
as well as a fellowshipdirector of clinical
neurophysiology.
I'm board certified inneurology, clinical
neurophysiology and epilepsy.
In addition to those clinicaland medical educational roles,
I'm also co-founder of themedical educational platform.
(00:48):
Now you Know Neuro.
Dr. Michael Kentris (00:50):
Awesome.
So I, as someone who also hasengaged in the online space,
kind of in the medical educationspace, kind of independently to
an extent, I was really happyto hear from you and to kind of
hear about sort of your journeyfrom and we can go back as far
as you want, whether med schoolresidency or wherever you think
(01:12):
it makes sense to kind of pickup the tail and kind of talk
about how you went from kind oftrainee to medical educator.
Dr. Brian Hanrahan (01:19):
Yeah, I love telling this story.
So to be honest, I was alwaysinterested in education.
My mom was an elementary schoolteacher.
I grew up in a family ofeducators.
In the elementary level I wasthe first physician in my family
.
I went to medical school andduring my medical school years I
still really enjoyedinteracting with the clerkship
(01:40):
directors and kind of learninghow medical education was done.
When I got into my neurologyresidency and I was starting to
prepare for the in-serviceexaminations, I just felt there
really wasn't very goodresources available for us to
kind of optimize our knowledgeand time to prepare for these
things.
So after I went to the AANconferences at PGY2 and kind of
(02:03):
just, you know, communicatingwith other leaders in the field,
I kind of realized that thismight be something I need to
kind of tackle myself.
So during my first, you know,pgy2, pgy3 years I started
working on developing sometext-based content for
preparation for the in-serviceand board examinations.
But I really didn't have anidea of how to kind of share
that information in the future.
(02:24):
I figured that would be afuture problem for me.
Fortunately, one of my juniorresidents, steve Gangloff, has a
lot of experience in codecoding and website design.
So I met with him kind of theend of my PGY3 year, beginning
of PGY4, and kind of gave him apitch of what we think we could
put together as an educationalresource for residents and he
(02:46):
was totally on board.
So now that was about longerago than I'd like to admit,
probably about seven or eightyears now.
We had the website launched,probably around 2019.
And then at that time it wasprimarily text-based chapters
and an image database withradiology, eegs, emgs and
(03:08):
pathology.
But since then we really havekind of evolved into having many
more modes of learning,including flashcards.
We now have about a 1300multiple choice question bank
and slowly adding more audiovisual content onto the site as
well.
Dr. Michael Kentris (03:27):
Awesome, yeah, I remember coming across
the website.
Unfortunately, I had been, likeyou said, also longer than I
care to admit, out of residencyfor a couple of years when I saw
it out there and I do thinkback kind of to that landscape.
Right, I took my boards in 2017.
(03:47):
And, as you said, there were ahandful of resources out there
in terms of like.
I was, fortunate enough, one ofmy attendings was Dr Esteban
Ching Ching, who kind of puttogether the for any of the
neurology residents out there,that uh kind of question
comprehensive review inneurology, I think is the title,
(04:07):
uh, which very uh frustratingbook, but also very good as far
as as a textbook is.
And then everything else.
It always seemed like, like youwere saying, all these
different residency programs hadtheir own little pockets of
like things that have beenhanded down generation of
generation to resident buthadn't really been widespread,
(04:31):
and it seems like this is kindof that writ large to an extent.
Dr. Brian Hanrahan (04:36):
Yeah, I mean it's something that has been
grown and fostered frominteracting with residents and
leaders in medical educationacross the country.
I think there's probably been50 to 60 people that have
touched it in some way, whetherit's writing a question,
reviewing a chapter, helping mewith the flashcards, giving
lectures.
So many hands make light workand it's crazy to think kind of
(04:59):
how large and robust it is atthis point.
And I think, mike, you hit agreat point of that.
You know smaller programs,newer programs, don't have that
internal resource available.
You can imagine, you know, whenI became an assistant program
director at my program, we juststarted it so we had to create a
like 200 hour lecture series inthe first year out of scratch.
(05:23):
You know incredibly hard whenyou don't have that.
You know those years ofresearch or old lectures kind of
build on to kind of get to thepoint where you're on the same
tier as well.
Established programs have beenaround for decades, not even
longer.
So this kind of helps programskind of get to that level very
quickly.
And it's great to see how sometraining programs have
(05:45):
incorporated my content intotheir curriculum.
You know whether it's question,review or in some other
modality, because it really.
You know, it's very rewardingto me to kind of see the amount
of influence I've been able tohave in people that I might not
even know personally myself, butit seems to have still some
value.
Dr. Michael Kentris (06:04):
No, that's excellent.
And one of the things I thoughtwas interesting is that you
know you do have on the websitethe option for, like, say, an
institution subscription as well.
And I'm just curious from yourown perspective when, like,
let's say, a residency programsigns up for you know the a year
or a board review series orwhat have you Does like, do they
(06:28):
find that there is an objectiveincrease in either board
passing rates or in terms oftheir in-service exam scores
going up?
Or what kind of metrics do theyreport back to you, or what
kind of feedback do you get fromthe users of your services?
Dr. Brian Hanrahan (06:44):
So subjectively, we get really
great feedback.
The one thing that we've kind oflearned is if we set up an
institutional account or evenlike a free trial for an
institution, you know, in thetime leading into the in-service
exam or just at the beginningof the academic year, the
retention rate is extremely high.
So if people didn't like it orfind it rewarding, they wouldn't
continue to stay with us.
(07:05):
It's a little harder to getthat objective data because I
think you know what metricswould we use.
Necessarily, you know you coulduse board pass rates.
You know, utilizing thein-service exam for something
like this is something I thinkthe AAM would probably not look
kindly upon, probably not lookkindly upon.
(07:25):
They would probably frown uponthat because of you know it's
really a marker of academicperformance and gives you
insight into how your residentsare performing and what you know
deficits they may have thatthey can focus their attention
on before the following year orbefore their boards.
So it's been hard to kind offind that objective data,
although we do have a lot ofsurvey-based insights into the
user experience and it's overallvery positive.
Dr. Michael Kentris (07:46):
Yeah, no, that's a great point.
I do remember as an anxiousfourth-year resident myself,
looking back to see like how youknow, how worried do I need to
be about my in-service examscores versus my likelihood of
passing my boards?
I think I only found like onepaper from like the early 2000s
or 2010s that was looking atthat Like there is an
(08:09):
association.
It was fairly strong, but notsuper robust.
Um, but yeah, it is one ofthose things that, uh, I think
you were absolutely right andyou know we don't need to lean
too much on the in-service examas far as board passing rates
and things like that, becausethat, as you rightly said, is
(08:30):
not the intent of the test.
It's not there to be apunishment or a scourge for
those who didn't perform well.
Hopefully more encouragement.
Dr. Brian Hanrahan (08:40):
Yeah, many PGY-2s come in thinking it's
something as serious as like ashelf exam in medical school or
something like that, and we kindof have to reassure them that
no, that's not how this works.
This is really just a marker.
You know, only the academicleadership at your institution
should know your performance andif anyone asks in your
interview season, you've got tolet us know, because they, you
know, we actually.
You know, I think the AAMencourages you to report that
(09:01):
type of behavior.
Yeah, another encourages you toreport that type of behavior.
Yeah, another thing to build onthat Mike, you mentioned that
research article.
You're right, that waspublished by the AAN.
I don't remember the exactnumbers off my head, but I think
there was like a 99 pass rate.
If your score was like 65% orhigher, yeah, so 65% of the
question is correct, right.
So that's pretty dated and theright exam has had some
(09:25):
dramatically dramaticimprovements in the curriculum,
the question content, the imagecontent, is now online based or,
I guess, electronic instead ofpaper based with a pen and
pencil, like you and I remembertaking it like and squinting and
couldn't see the pixelated grayfigures.
So they've done a great jobimproving that exam and they've
(09:48):
made a lot of changes to reflectsome of the blueprint for the
ADP exam.
So at the AAN conference thisApril they announced that
they're going to do anotherreview of the performance on the
NSERF exam in relation toboards and hopefully that should
be coming out in the next yearor so.
So I'm really curious to seewhat the new data is.
(10:09):
Because the exam is now sodramatically different.
Because that's really somethingthat I need to know as a medical
educator when I'm, you know,communicating with my trainees,
because realistically I kind ofwant to know what is the
threshold for my graduatingclass to perform at, for me to
say you have nothing to worryabout, or to put someone on
alert and say, listen, youreally need to buckle down and
(10:30):
spend a lot more time learningand paying attention and
focusing on these aspects.
They do give you that kind ofdetailed breakdown of not only
what subjects people struggledin but also what topics whether
it's an easy, medium, hard theystruggled in and also like at an
institutional level too.
So I think that's really greatas a medical educator to review
(10:51):
all that information to kind of,you know, potentially make some
modifications to yourcurriculum in any individual
year If you know that yourschool struggled in you know
neuroinfectious diseases, thatmight be something you want to
add one or two lectures on.
You know in neuroinfectiousdiseases that might be something
you want to add one or twolectures on.
Dr. Michael Kentri (11:06):
Incorporated throughout the academic year.
No, that's great, and I doremember anecdotally my own
scores and I like to think thatthey're fairly representative of
most junior residents back then, which would have been like
neuro-oncology pediatricneurology which would have been
like like neuro-oncology,pediatric neurology, yeah, um,
(11:31):
and then a lot of times,especially as a PGY2, like a lot
of the pathology, likeneuropath questions.
Uh, those are always one of thethings that are just like ripe
for questions.
Yeah, and I, I remember, as yousaid, it's it's someone who's a
little bit away from that nowand not working directly with
neurology residents as often.
Who's a little bit away fromthat now and not working
directly with neurologyresidents as often um, there was
.
There was always a lot ofcomplaining when the right uh
right exam time came around,because there's like such a
(11:53):
disconnect in terms of what theywere asking you versus what you
are likely to be seeing on yourboard exams that it was felt
you know, to use some extremelanguage like a waste of time.
Uh, uh, to an extent, whichprobably a bit of an
over-exaggeration, but we allknow how, how you can be when
you're in residency and tiredand frustrated, um, but yeah any
(12:14):
core, any core faculty memberin medical education, in
neurology are going to hear thatafter the exam like, oh, they
asked these mundane, intricatelittle questions.
Dr. Brian Hanrahan (12:23):
Um, but you know I always kind of explain.
There's, you know, there'sclinical fund of knowledge, like
practice practicing fund ofknowledge, and textbook or board
exam fund of knowledge.
And yes, there's significantoverlap but there's a little bit
on each side of those that arenot going to be applicable to
both and you just have to beaware of that and really focus
your time when you are learningindependently on those kinds of
(12:46):
things that are outside thatVenn diagram.
I think one of the biggestcriticisms you could have about
the in-service exam as an adultneurology resident is that they
do have a lot of pediatrics anda higher percentage of pediatric
neurology on it compared towhat you're going to be taking
on the adult neurology boardexam, and it's because it's
created to be taken by bothpediatric and adult neurology
(13:09):
residents.
There are some discussionsagain in April this year of
possibly separating out thepediatric and the adult
neurology residency and serviceexaminations, which I actually
think would be a great idea,because then you'd be able to
have the exam more reflective ofwhat those future trainees are
going to take and with, I think,the team that they had in the
(13:30):
AA, and I think they definitelywould be able to create, um, you
know, a question bank thatwould 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 similardiscourse as well, uh, from some
of our child neurologycolleagues.
I've heard similar discourse aswell from some of our child
neurology colleagues, and, yeah,it is one of these things where
we see this continued I hate touse the word balkanization like
even within neurology, adultneurology, and there's just such
(14:03):
a vastness of information thatit does become almost
challenging to say, like, whatshould a graduating general
neurologist know?
And that's, I think, becoming aharder question to answer at
times.
I'm curious what yourperspective is as someone in
kind of more involved intraining residents at present.
Dr. Brian Hanrahan (14:19):
Yeah.
So it is definitely gettingharder, I think, to figure out
what esoteric information isreally needed, and I think both
you and me, Mike, now we've beenaround long enough, as much as
we wouldn't like to admit tohave seen that kind of evolve
over time.
Because I think historicallythere was a lot more neuropath
(14:39):
evaluated, a lot more of thebiochemistry, isosomal storage,
diseases, things like that thatare being incorporated, but now
things are just a little biteasier to do.
I think the role of aneurologist has evolved over
time too, and I think one of thehard things too is just the
evolving range ofneuropharmacology available.
(15:01):
If you think about just likeall the MS therapies that have
been approved in the last fiveyears, it's overwhelming.
And how much of all of that doesa neurology resident need to
know, being that they might notreally be practicing that aspect
in great detail?
I think that's a big strugglethat a lot of question exam
(15:24):
companies struggle with, becausewhen you are at creating, you
know questions or teachingpoints that are really
(15:48):
reflective of what afoundational trainee would need
to know.
So there's always that constantbattle.
So when we have like peoplecontribute to now you know neuro
, I actually usually like tohave people that are more in the
higher tiers of their graduatemedical education or just out of
training or in residence or infellowship, because they kind of
(16:09):
have a better idea of what thatfoundational knowledge is, as
opposed to like that super subspecialized components.
Dr. Michael Kentris (16:15):
No, that's a that's a great point.
It kind of puts me in mind ofsome of that YouTube video
series where you know, like aphysicist explains black holes
at five different levels.
You know down to, like a kid ina garden, or up to another
another PhD.
Yeah, Like you said.
(16:37):
It's exactly what you said.
You get these deep, deep, likethey're at the cutting, bleeding
edge of research and you getall this minutiae of these drugs
coming down the pipeline and wethink they get really
mechanistic and maybe thegeneral neurologist out there
just needs to know do I need tocheck liver enzymes periodically
(16:58):
on this medication, or what'sup?
Dr. Brian Hanrahan (17:01):
When do I refer to a specialist?
yes, exactly when do I submitthem into the epilepsy
monitoring unit, things likethat, right, yeah, and I?
That's that ability tocommunicate at.
You know, what I argue is likean eighth grade reading level is
really also can be um valuablein patient care, right?
One thing I've also haveexperienced when I work with
(17:22):
newly graduated medical studentsin residency is that they have
this huge fund of knowledge theywant to show off right, because
they've worked very hard to getto where they are.
And then when they'recommunicating things to their
patients, sometimes it's at ahigh level where you would need
to have that graduate degree tofully comprehend the whole
conversation level where youwould need to have that graduate
(17:43):
degree to fully comprehend thewhole conversation.
But being able to communicatethat in a very easy way or
really understandable way wouldbe something that your patients
are really going to appreciate,right, because then they
actually have understanding oftheir own health.
Dr. Michael Kentris (17:55):
Yeah, I know I was guilty of this the
other day because I always askthe patients when I'm explaining
something how much do you wantto know, right?
So I was talking aboutfunctional neurologic disorders
with someone and they wanted toknow more.
So I was like, so we talkedabout the interoceptive network
for a few minutes, which I youknow, to be honest.
(18:17):
Right, it's one of those thingsthat, again, right, we don't
necessarily learn as much inresidency, but you and I, we
both did epilepsy fellowship andit's something we see all the
time.
So I have this book now on myshelf where I kind of go back.
I got the clinical foundation,now I can go back and dive into
(18:40):
some of the neuroscience.
I got the clinical foundation.
Now I can go back and dive intosome of the neuroscience
instead of being a pretendneuroscientist, try and get some
of the actual foundationalinformation there and read more
about some of these things thatI hear these researchers talking
about.
So I have some foundationalunderstanding and hopefully I
can use that information that Iaccrue to explain it in a more
(19:00):
clear and concise manner, asopposed to, like you know, like
uh, for those who are familiarlike the common analogy uses,
like the software hardwaremismatch um, which, you know,
not entirely accurate, right,like most analogies, it breaks
down at some point, but butright.
The more we know, the morecreative we can be in terms of
our descriptions and hopefullycommunicate things more
(19:25):
accurately, kind of meeting thepatient 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 whattheir, their understanding is of
that diagnosis to begin with,right to begin with right.
Especially again in that realmof conversion disorder or
non-epileptic events, there issuch a stigmatization of that.
They may have been told thatthey're crazy, that they're
doing some purpose.
It's all in their head, likeall these kind of huge things
(19:51):
that are obviously nothing thatany trained epileptologist would
ever say in a patient room.
It really kind of helps you getit up, preps you for that type
of conversation and seeing howmuch empathy you know is needed
to kind of convey some of theseteaching points or these
educational points for thepatient.
Dr. Michael Kentris (20:09):
Absolutely.
Now, one thing I'm curious tohear your perspective on is, you
know so I was at a neurologyresidency for my first few years
out of training and I moved andI'm currently at a community
teaching hospital.
So most of my educational roleis dealing with non-neurology
residents, so internal medicine,family medicine, emergency
(20:30):
medicine and so kind of thesefrontline primary care
physicians or physicians to be.
Well, no, they're physicians,they're soon to be independent,
and so getting them acclimatedwith common neurologic disorders
that you know, I try and do mybest to identify, like, what are
the most important things thatthey need to know, if they're,
(20:52):
you know, because there's plentyof neurology deserts throughout
the country, you know, letalone throughout the world.
So how can we get these primarycare physicians to kind of get
the essentials down so that theycan hopefully manage some of
the more common disorders outthere?
And I'm curious, like insomeone who is in a more
structured teaching role, how doyou find that integrates into,
(21:15):
kind of the overall structure ofthe neurology residency program
?
Dr. Brian Hanrahan (21:20):
Yeah, I mean we have.
I think every neurologyresidency program would probably
still have trainees rotating ontheir services that are outside
neurology, right, you know, ifpsychiatry has to do neurology
exposures, internal medicinewill come through.
If you have neurosurgery, youknow they may be rotating in
your vascular neurology or inservice services.
And I think it's reallyimportant that you have some
(21:41):
personalization based on youknow the type of training that
person has and also how muchtime you have with them.
Right, you know if you onlyhave, like you know, a week with
them, you know how much arethey going to get out of that.
You're kind of limited andyou're not going to cover all
the bases, but whenever I dowork with anyone outside of my
residency program, I kind ofalways want to know what their
(22:03):
future goals are regarding theircareer, like what career path
they're going into.
So then I can kind of modify myeducational teaching points
based on those components.
Right, if someone's going to bebecoming a neurohospitalist, I
might focus more on, like theultimate mental status
evaluation, first time seizure,you know, values of an
interpretation of CT scansversus MRIs.
(22:25):
If they were outpatient, thenyou're going to be focusing more
on the ketic management.
So it could be doing someepilepsy or seizure for syncope.
You know that's a very commonoutpatient.
So trying to get thatsubspecialization based on their
career goals I think reallyhelps those people leave with
the type of fund of knowledgethat would be the most valuable
(22:46):
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 anddo that as well the ebb and flow
of the hospital and the clinicsometimes doesn't always lend
itself as well as we would liketo getting them that direct
patient experience.
But but I think those are allgreat points.
Um, do you find like, in termsof um, your neurology staff or
(23:14):
even the neurology residents?
I remember, as a residentmyself, we would sometimes go
like to our, our psychiatryresidency colleagues and we'd do
some of their lectures like alot of times as part of their uh
in-service exam prep and wewould usually be scheduled uh
kind of on a rotating round fordifferent topics and so forth.
Um, just curious perspectivelike resident as teacher versus
(23:37):
attending as teacher.
Any significant opinions orperspectives?
Dr. Brian Hanrahan (23:42):
Yeah, I mean I think that's a common
attribute in all residencyprograms is to have your own
trainees, educators, within theprogram, as well as trying to
have people outside of yourresidency involved as well.
One of the best ways to learnis to teach, is I really do
believe that mantra, and itreally kind of pushes you to
have that fund of knowledge tobe able to not only present the
(24:05):
information but probably be ableto also address follow-up
questions as well.
For what it's worth, thepsychiatry has their own
in-service exam equivalentcalled the PRITE.
It's administered in the fallevery year.
So there are opportunities.
I think, because there is asignificant overlap between the
curriculum of the APPNpsychiatry exam and the
(24:26):
neurology exam, that there isthings that can be addressed in
both of those avenues,especially neurocognitive
diseases, neurodevelopmental,you know.
Even some basic neurology likemovement disorders and stroke
are going to be seen on yourpsychiatry Right.
Dr. Michael Kentris (24:41):
You know something, I, something I know
again, right in the epilepsyworld, I think it's around 80
percent have some sort ofcomorbid psychiatric diagnosis
as well.
Um, so it's, you know, a lot oftimes neurologic and psychiatric
disease travel together.
And something I had looked upactually in the past is that if
(25:01):
you look at the number ofpsychiatry versus neurology
training programs, I thinkthere's something I want to say
around 100 or plus more thesekinds of programs doing as far
as their neurology exposure.
They may have private practiceneurologists or
(25:28):
hospital-employed neurologists,but it's not as integrated or
structured per se as what wemight see in a place that has
both a psychiatry and neurologyresidency training program and
neurology residency trainingprogram.
And then, just to take that tothe you know, further extreme,
if you look at the number ofinternal medicine residency or
(25:48):
family medicine residencytraining programs out there
versus right, we're talking, youknow, a mismatch of like 10 to
20 to one right.
So these places are definitelygoing to have I, I again right,
I'm making some assumptions, butI can only imagine they would
have a less structured, uh,educational experience in the
neurosciences as compared to aplace that has a residency
(26:11):
training program in neurology.
I don't know, is this somethingthat'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 andneurology residency uh programs.
You're right in the fact thatthere's for every one neurology
resident there's threepsychiatry ones.
Um, so it's a much larger uhfield of medicine.
For I think, for a lot ofobvious reasons, um, you know,
we do um have our uh.
I think the amount of trainingthe psychiatry residents do in
(26:40):
neurology is is, um, probablycomparable.
I think the amount of trainingthe psychiatry residents do in
neurology is probably comparable, I think, to the amount of
neurology residents do inpsychiatry.
So it's not like a verysignificant amount of time where
you are in that otherrespective field.
So just enough to kind of get ataste.
Get a taste.
(27:03):
You're right that you'd thinkthat if you're not at a very
large, robust academic programwhere you have both neurology in
addition to your psychiatry,the training might suffer.
But I mean, that's true, foryou can say that same thing in
medical school, right?
So a lot of DO programs don'trequire neurology as a core
rotation.
So a lot of these people areending up, you know, looking for
electives that might not be asacademically, you know, versed,
(27:28):
but I think you try to find thebest opportunities out of that
to optimize the learningexperience 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 ownexperience, right you kind of
would cold call places and belike, hey, could you take a
medical student in February thisnext year?
And sometimes they would sayyes, sometimes they would say no
, and yeah, it is one of thosethings.
(27:55):
I think it's something like athird of medical schools don't
have a neurology clerkship,right?
So there is this lack ofexposure 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 additionaladversity to overcome, a lot of
people are still able tosuccessfully, you know, match
into neurology residency stillable to successfully, you know,
match into neurology residency.
Dr. Michael Kentris (28:23):
Yeah, yeah, and it's.
It's very interesting, uh, whenI talk with a lot of people in
uh, medical education withinneurology, we talk about like
this, this pipeline from medicalschool 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% ofprograms filled in the match.
Dr. Brian Hanrahan (28:43):
It was 99.
There was like one spot out of878 that didn't match.
Dr. Michael Kentris (28:47):
Right, which is wild right.
So I don't know if that's theissue anymore.
I think what we're reallysuffering from is a lack of
neurology residencies, like weneed more programs to make more
spots so we can drive thatnumber 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 wasactually reviewing in
preparation for this meetingtoday, neurology residency
programs are growing about likea 2% rate per year.
So that's the number of spots.
So when you and I were intraining we were probably closer
to 800.
Now we're closer to 900.
(29:27):
We might get over 900 in thenext year or two, with programs
continuing to grow and new onesstarting.
And yeah, it's nice to see thatit's one of the programs, one
of the training subspecialtiesthat are so easily filled.
Yeah, it means that you know weare definitely a training
(29:50):
subspecialty that has as manyspots, if not enough, for people
that are interested in it.
And yeah, and it's somethingthat you have to kind of reflect
and look at over time becauseyou know some residency programs
are not our residencysubspecialties are not seeing
that same interest in the fieldand other ones are growing
exponentially larger over timeevery year compared to us yeah,
(30:13):
yeah it's.
Dr. Michael Kentris (30:14):
it's definitely very interesting from
that perspective and it doesmake you wonder um right,
because, like we've've those ofus again who are kind of in this
space there, there've been afew papers over the last five,
seven years talking about theprojected mismatch of demand
versus, like, practicingphysicians, and it's only
(30:37):
expected to kind of get worseover the next 10 to 20 years.
Dr. Brian Hanrahan (30:41):
For sure.
Yeah, it's, it's, you know itlooks like.
If you look at the data, youknow they have that, that graph
of you know years, with on the Xaxis and on the Y axis, the
number of positions, and it'sgrowing at the fastest rate it's
probably ever have, sincethey've been keeping track of
the data.
But there's, they haven't had amatch of number of applicants
(31:03):
to the number of positions sincethe 1970s.
So it would be something that Ithink they'll never catch up
with, because I think everyonewants to be a doctor.
So there will always be aninterest, and I think there's
also a huge you know growth ofinternational applicants too on
(31:24):
top of all of that.
So, you know, we're not only umaccepting people within the us
uh, you know medical educationsystem, but a large fraction out
of international graduates tooright, I think it's, and I
apologize, I'm a little vague onsome 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 practicingneurologists are international
medical graduates.
Dr. Brian Hanrahan (31:46):
Yeah, so 204 of the 878 matches this year
were international IMGs, andthen additional 55 people were
US IMGs.
Dr. Michael Kentris (31:58):
Yeah, that's.
I mean right, it is one of thosethings.
And something that's very, veryinteresting to me also is and
again, I don't know how familiaryou are with it, so again, but
the like the visa program in theUS for for some of these
graduates it's cause, you know,at our program here we'll have,
for instance, a lot of IMGs inour internal medicine program,
(32:23):
but the hospital, even though weare fairly remote from a lot of
bigger cities we're like 50, 60miles away from Cleveland,
pittsburgh, we're kind of in themiddle of our own area and we
(32:51):
have a very underservedpopulation, both in the urban
centers as well as rurally thatwe don't necessarily fall under
the classifications for anat-need designation for some of
these visas.
And when I hear this, I'm justlike you've got to be kidding me
Because we don't meet thesecertain criteria.
But you look around with youreyes and you're like we
definitely need them, though,and it can definitely be a
stumbling block for a lot ofpeople to find jobs after
(33:12):
training, and I don't knowresidents coming through your
program.
In terms of visa status andthings like that down the road,
is that something that you kindof 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.
I know it's something that manyresidency programs take very
seriously and in the process ofscreening people to know what
type of visas they would requireand if their institution is
willing to support those typesof visas, and you know, I think
the biggest thing that you hiton is the fact that you know,
(33:42):
after you're done with yourtraining, you need to be
somewhere.
I believe in an underservedpopulation and I don't
understand the or not that.
I don't understand.
I just actually don't even knowthe criteria that need to be
met by a hospital system orindividual hospital to meet the
criteria.
But it seems like it's prettythere's not that many in
(34:02):
relation to the many ofhospitals that are out there.
So it is an extremely stressfulsituation 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 thatthey have to go through that in
comparison to US grads whichare really kind of having they
have a wide open door prettymuch 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 upagainst when I've had folks
where we're trying to recruitright a very small department
here and we're kind of cuttingout 25% of the pool right out of
the door and that obviously isnot ideal from a recruitment
perspective.
(34:46):
So just my own personalfrustrations on that one also
aspect.
You know, kind of looking atthe international neurology
education front, do you findthat in addition to kind of like
(35:07):
US-based programs, do you findthat you're like now, you know,
or other kind of educationalthings that you've done in the
past, are utilized byinternational training programs?
Dr. Brian Hanrahan (35:17):
Yeah, actually we have had a few
institutions reach out forinstitutional accounts.
One of the ones I would mentionis there's a program in Jordan
that utilizes it.
They have a neurology residencyprogram there and has been well
received.
They renewed their account thispast year.
I think one of the uniquethings that are going to be
(35:38):
happening over the next decadeor so is there's this evolution
of something called iACGMEprograms.
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, peoplewould be able to be educated
internationally and kind of meetthe the accreditation criteria
for acgb certified programs.
Interesting, um, there's notmany out there and I think the
(36:07):
last time I checked I can't evenremember if there's any in
neurology, um, but it's a reallyinteresting avenue because
there is a lot of limitations ingraduates internationally for,
you know, future employment inin America because of that um
restriction, um, so yeah, we dohave some international uh
programs.
Uh, we do have a lot ofinternational people attend our
(36:29):
virtual sessions.
You know, in in uh January andFebruary every year we host five
to six hours of lectures liveon Zoom.
We then end up eventuallygetting to our library that all
our users can access.
But I'd say I think over athird of people are
international people looking tolearn a little bit and since we
have over almost 3,000 followerson Instagram, we have a huge
(36:53):
audience.
That's well above and beyondyou know what a normal or not a
normal, but uh, the probably thefull 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 whereyou might feel like you're
sitting in your home office oryour office at work and you're
just talking to a screen, but uh, if there's, you know, a
thousand plus people on theother end of that recording
right, that fills up a prettydarn 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 reallyinteresting because I think
we've all known one of ourcolleagues 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 inthe Midwest or you know China or
(37:45):
Southeast Asia, what have you.
And it's like, oh, I was, youknow, a surgeon there, or I was
a neurologist there, and theyhave to come back and repeat the
training and it just you haveto 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 trainingalongside many people with that
career path but you know youhave to really um empathize with
that experience and you know Ihave interviewed, definitely
people that have gone throughthat process themselves and you
know that kind of shows youtheir drive and their
(38:23):
willingness to pursue this fieldof training.
You know some medical educatorsI interact with have always
said that you know theinternational medical, you know
trainee cohort are usually someof the hardest working.
You know the internationalmedical, you know trainee cohort
are usually some of the hardestworking.
You know trainees they have attheir programs.
Because of that reason, becausethey've had to work so
incredibly hard to get to wherethey are They've really,
(38:47):
unfortunately, I've had tosacrifice many things to get to
where they are in their careerthat 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 workridiculous hours for, you know,
three plus years, depending onyour program of specialty of
choice, and yeah, and plunk downusually thousands of dollars to
do it.
Um, yeah, there's a, there's acertain amount of grit that it
(39:19):
takes there for sure.
Um, as far as kind of peoplewho are looking to get into
medical education maybe they'reat a smaller institution or they
don't have something structuredwhere they are what kind of
recommendations do you have?
It sounds like you kind of justbootstrapped this thing up, but
(39:42):
what kind of suggestions wouldyou have?
Or where would people start?
If, let's say, we've got a newneurology attending who's kind
of out in the middle of nowhereon 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 peoplethat are earlier in their
careers to try to mentor them.
At this point I will say youknow, I did have someone like
that guiding me early on in mytraining.
So that was Ralph Josefowicz.
He was the program director ofthe University of Rochester for
many, many years.
He actually was the physicianthat first published the term
(40:18):
neurophobia many years ago.
He was a huge person involvedin the AAN community.
He ran a mind-brain behaviorcourse for the more junior
medical students at hisinstitution and I did an acting
internship at that program whenI was in medical school and he
gave a lecture on the careerpath of a medical educator,
(40:40):
which I still have and I stillrefer to every once in a while,
and he broke it down as earlytraining, early career, mid
career and late career, andobviously the early career was
kind of things that I found mostapplicable to me at the time
and some of the things that werediscussed in that included
finding a good mentor, lookingfor opportunities, saying yes to
(41:02):
everything, becoming a leaderin medical education at your own
institution and then, as yougot into extended phases of your
career, you start to getrecognition from a national or
even an international range.
So that's really what I focusedon.
As a resident, I got an award asa medical student educator of
(41:25):
the year and then as a fellow atRochester I got fellowship
educator of the year.
I got involved with the AAMcommunity in their NeuroReady
board prep course, actually as afellow, the youngest person on
that team at the time and then,you know, at other programs
(41:59):
regionally close or virtually aswell.
So you know, to summarize, youknow look for mentors, look for
opportunities and if you'rereally going to pursue a
graduate medical educationcareer whether it's like a
clerkship director, fellowshipdirector, fellowship director
you really kind of need to startby getting your foot in the
door in some way.
(42:20):
Working in the resident clinic,you know, having trainees rotate
with you in clinic givinglectures and then hopefully that
would transition to moreleadership positions that are
not things that are consideredcore or time.
So that could be being part ofyour program evaluation
committee which meets, you know,intermittently throughout the
year that reviews the curriculumor the training experience of
the trainees, the clinical, theCCC, which evaluates resident
(42:48):
performance, and giving feedbackof what needs to be done if
anyone is in risk forremediation or anything along
those lines to be done.
If anyone is in risk forremediation or anything along
those lines, and then as you getmore kind of non-protected time
leadership positions as otheropportunities open up, then you
would be the one that would befirst considered for those roles
.
So very often you might getyour first foot in the door and
(43:10):
then in a few years you mighthave started getting your first
0.1 or like four hours a week oftime towards these more
educational roles and then, asyou become, if you have the
opportunity to become a programdirector or an assistant program
director, that can besignificantly more time.
Dr. Michael Kentris (43:24):
No, that's great advice and it is.
Yeah, it's one of those thingsI'm still working out myself
where you say yes to everythingand at some point you do have to
start saying no to things andit'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 toeverything 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 thinand I've had to say no to a
couple opportunities.
For example, I was for a littlewhile I was involved in the
interviewing of medical studentsfor the program I'm at and did
a couple of those.
But because of the day thatthey were doing the interviews
and having it kind of run inline with our resident interview
(44:08):
season, it just wasn'trealistic for me to be involved.
I wasn't able to really give itmy full effort.
I wasn't immersed enough tomake it an full effort.
I wasn't immersed enough tomake it an efficient process
because I had to kind of relearnthe system, the platform and
the process every time I did aninterview here and there.
So by the time you really startsaying no, that's kind of when
(44:31):
you already have your foot inthe door, so to speak, and
really trying to be reflectiveon like, how would this optimize
my career path, my career goalof becoming a program director,
a clerkship director, or eveneven, 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 whenyou're first out of training.
But I think you had referencedthis earlier.
Dr. Brian Hanrahan (45:00):
It's kind of like finding that mentor,
someone who's kind of doing whatyou're doing or what you you
also need to be very focal aboutwhat your goal is Right, I
think if, if no one knows thatthat is a career path you're
pursuing, they won't consideryou or maybe even offer you
(45:22):
opportunities to kind of buildyour educational profile to be
considered when that opportunitybecomes available so telling
your head of your department orthe program director that you
currently are associated with,or something you know, let me
know.
I'd love to do whatever I canto be considered for a core
(45:44):
faculty position when the nextone becomes available.
What kind of career path orwhat steps do you think I would
need to complete to get toconsideration when that happens?
Dr. Michael Kentris (45:50):
Yeah, no, those are great things.
Yeah, I know I've gotten awayfrom from the pure academic
employment setting myself, sothese are considerations that I
have long ago put to the side,unfortunately, but it is.
I know there's a lot of folksout there who are in that
setting and it's always goodbecause you know everyone's
(46:14):
employment situations or workenvironment can change over time
.
So it's always good to kind ofuh remember these things because
it is.
It is its own unique animal interms of like kind of the, the
academic hierarchy and structure.
Dr. Brian Hanrahan (46:38):
GME model or leadership, is totally
independent of your clinicalcare model.
So knowing kind of who tocommunicate for certain aspects
of your career are important andthe turnover is pretty high.
The last time I heard, Ibelieve, a program director's
average lifespan is about fiveyears, so many of us would be
practicing for 30 plus years intheir lives.
So if they're at the sameinstitution that whole time,
there might be five, six timesthat there's turnover in that
leadership.
Be practicing for 30 plus yearsin their lives, so they may, if
they're at the same institutionthat whole time, there might be
, you know, five, six times thatthere's turnover in that
(47:00):
leadership position, whichprovides a lot of opportunities
for you know more time and moredifferent roles.
Dr. Michael Kentris (47:06):
Yeah, no, that's a great point.
You know they don't want thingsto get stagnant and it's always
good to get fresh blood, freshperspectives, things like that
kind of in there, Although youcertainly hear stories about
these kind of legendary programdirectors out there who've done
it for 10, 20 years and thingslike 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 roleand are really passionate about
their job.
Ralph DeCefalo, which is one ofthem.
Deb Bradshaw at University,SUNY, Upstate, was there for
many years.
Zafar Khan, I believe.
He was there for many years atEmory as well, you know.
I think Chris Lee at Vanderbiltnow has been there for a good
(47:46):
amount of time too.
So I mean and there's many morethat I'm forgetting but you're
right that the longer someoneusually is in that position,
that usually means that they arevery, very good at their job
and really passionate about ityes, any final thoughts?
Dr. Michael Kentris (48:03):
uh, any advice to those kind of early
career, you know, whetherthey're med students interested
in neurology or residents orfellows.
Um, I know we've kind of gonethrough a lot of that stuff
already, but like if you had tosummarize your best
recommendation for peoplelooking to pursue a career in
academics or kind ofbootstrapping their own academic
(48:26):
projects.
Dr. Brian Hanrahan (48:28):
Yeah, I mean , I think, regarding projects
and research.
I think that's something that alot of trainees don't have a
lot of experience with and theyvery easily can get guided into
a wrong path or a veryinefficient path.
So whenever I talk with mytrainees and they're coming up
with study designs or questions,I usually have them answer
(48:49):
three questions before we getstarted.
One is do you have a goodquestion, like is this something
that people are going to careabout, or is this question
already been answered?
Two, you know, do you have agood study design?
So, no matter what, if you havea very good question, if your
study design is garbage, noone's going to accept it because
it's just not a good study.
And three, do you have arealistic timeline?
Do you really have the time tosee the study through and
(49:10):
through?
You know, if you're a medicalstudent, you have three more
months at your training programbefore you go into residency.
You're not going to write anIRB for a study that takes three
years to collect data on right.
So you know, if you are able toget those three things
identified and I'm satisfiedwith it you'll get the green
light for me to pursue.
But you know, mike, I'm sureyou have, just like I, have been
(49:34):
involved in projects that justwent nowhere, and I mean I
probably have wasted dozens anddozens, maybe even hundreds of
hours of research time intoprojects that maybe got an
abstract at a conference thatcould have easily been
comparable to a case report Iwrote in 30 minutes minutes.
(49:57):
That is so frustrating, youknow, and as a medical student
or an early resident, you don'thave 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 aspectsand thinking about how this
actually will help you yourcareer path forward is really
something really important.
The Now you Know Neuro Instagrampage is something that I follow
.
I create.
(50:18):
I'm the one that probablyreviews it almost daily.
I'm the one that makes all thememes.
For anyone that was curiousabout that, you know we also,
you know, have info atnowyouknownneurocom.
If you want to email us aboutyou know, setting up an
institutional account, you canfind that on our website at
nowyouknownurocom.
For anyone who is interested inpsychiatry, we actually launched
(50:40):
a sister product called Now youKnow Psych for psychiatry
residents.
They also have a thousandflashcards, chapters, question
bank, pretty much everythingcomparable to, now you Know,
neuro for psychiatry residentsand we're hoping to grow that
over the next year or two.
And additionally, we'll belaunching, actually an
application very soon called,now you Know, med, which is
(51:05):
going to be housing our questionbanks and our flashcard decks
for both neurology andpsychiatry residency resources.
So you know that'll be a mobileapp available.
You know, in the next couple ofweeks, if not a month or two,
that I think a lot of lot of ouruh subscribers are going to be
very excited about, becausethat's probably one of the only
things that kind of um aredifferent from our resources
compared to you know more of thesome of the better known ones,
like uh board vitals and andthings like that.
Dr. Michael Kentris (51:28):
Awesome.
No, that's great.
Um, so again, right, thanks forthank you everyone for
listening.
So again, thank you everyonefor listening.
You can, of course, find me onTwitter, slash at Dr Kentris,
and then you can always checkout theneurotransmitterscom for
more information about all ofour work.
Dr Hanrahan, thank you so muchagain.
(51:49):
I appreciate the talk and Ialways enjoy getting a fresh
perspective on medical education.
It's always refreshing to me totalk to someone who's kind of
at least, if not more, into thisstuff than I am, so I
appreciate you taking the timeto talk with us today.
Dr. Brian Hanrahan (52:06):
Pleasure of mine, Michael, and great to see
kind of this neurotransmittercommunity grow and develop over
time.
And I'm sure you've beenstrategically you're you've been
strategically and significantlyinvolved in helping that foster
and grow.
So I wish you all the best withfuture growth and development
and love to be more involved asthings move on.
Dr. Michael Kentris (52:25):
Thank you Appreciate it.
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