Curriculum Innovations: Improving Residents' Knowledge and Interest in Outpatient Neurology Through an Interactive Patient-Centered Didactic Series

Introduction and Problem Statement

The majority of neurologic care is delivered in the outpatient setting. Despite this, most neurology residency programs remain inpatient and intensive care focused.^1,-,3 This leaves many trainees with insufficient knowledge about outpatient-based specialties and inadequately prepared to take on the specific roles and responsibilities required of outpatient providers, such as longitudinal management and effective shared decision making (SDM). A survey of program directors identifies a need for more outpatient training and dedicated conferences.⁴

To address this gap, we implemented a novel didactic series involving facilitated interviews between a subspecialist outpatient neurologist and one of their patients. The series format is unique in that both a subspecialty neurologist and one of their patients are present together in person to teach residents. We chose to include patients in these sessions to facilitate residents' learning about how management decisions and the impact on the patient change throughout the course of chronic neurologic conditions. This article reports on the implementation and evaluation of our series. Our results offer guidance for neurology and other training programs seeking to expand residents' exposure to outpatient topics and care.

Objectives

We developed and implemented the Patient-Centered Outpatient Management Series. The objectives of this series are as follows:

1. To improve residents' understanding of the roles and responsibilities of the neurologist in the outpatient setting.

2. To share with residents the patient's perspective of living with chronic neurologic disease.

3. To improve residents' understanding of what effective SDM entails.

We hypothesized that the participation of patients would enhance the educational value of the series and provide an engaging approach to teaching SDM.

Methods and Curriculum Description

Results and Assessment Data

Pilot Evaluation

Residents

Fifty-five postsession questionnaires were completed—3 by PGY-1 residents, 9 by PGY-2 residents, 17 by PGY-3 residents, and 9 by PGY-4 residents. All resident responses indicated that hearing the patient perspective added educational value to the conferences (Figure 1). Ninety-five percent felt that this format is more effective than lecture at delivering educational content about the topics chosen, and 97% affirmed that the knowledge gained would affect their clinical practice. Seventy-eight percent of resident respondents indicated that they had followed no more than 1 patient with the problems highlighted in these conferences during their residency, with 60% having never followed a similar patient (Figure 2). Even among the 9 PGY-4 resident responses, 5 had followed 0–1 representative patients.

• Download figure
• Open in new tab
• Download powerpoint

Figure 1 Pilot Program Resident Survey Responses

Resident responses (n = 55) to survey questions distributed at the conclusion of each of 6 sessions during 2016 pilot program.

• Download figure
• Open in new tab
• Download powerpoint

Figure 2 Number of Representative Outpatients Followed per Resident

At the conclusion of each of the 6 sessions in our 2016 pilot series, residents were asked how many patients they had followed who had the specific condition that was the focus of the session. For example, “How many patients with migraine have you personally followed in clinic that are receiving an interventional therapy (e.g., botox, nerve blocks)?” Responses (n = 55) were aggregated across the 6 sessions and expressed as a percentage of residents responding in each category. PGY = postgraduate year.

Three themes emerged from residents' written comments:

1. The central value of the patient perspective: Residents reported that hearing directly from the patient was the most useful aspect of the sessions and described this as “fun,” “poignant,” “effective,” and a unique experience “we don't often see as…residents.” Residents appreciated hearing about problems that patients personally identified as being important to them. For example, the individual with ALS volunteered that he had thought about suicide, an uncommon topic in lectures on ALS.

2. The session format supports learning about outpatient management: The diseases and management issues covered in these sessions were rarely seen during residents' clinical rotations; residents felt that the series offered a “perfect format to address [the] topics chosen” and highlighted “the importance of SDM” among other topics in outpatient management.

3. Seasoned faculty served as role models: The perspective of seasoned outpatient clinical faculty was felt to be additive and dovetailed with the patient perspective. Faculty served as role models for communication witnessed by residents in real time. Furthermore, hearing a balanced perspective of both parties side by side informed the contributions of faculty and patients to the decision-making process.

Table 1 includes a summary of the key themes and representative quotes from residents identified in the 2016 pilot evaluation.

View this table:

• View inline
• View popup

Table 1

Major Themes From Qualitative Evaluation of Pilot Program (2016–17) and Select Illustrative Quotes

Faculty

Five of 6 faculty completed the survey. All faculty enjoyed leading the sessions and found the sessions to be easier and less time consuming to prepare for than lecture. All agreed that the format was more effective than lecture at delivering educational content about the chosen topic. All felt that having the patient present was essential to the success of the conference.

Qualitative responses highlighted faculty's appreciation of the opportunity to discuss practical, patient-centered issues distinct from book knowledge topics. Faculty also felt that the session strengthened their relationship with their patient. Key themes are summarized in Table 1.

Patients

Postsession interviews were completed for all 6 sessions—5 patients and the father/caregiver of the patient with TBI. All respondents would participate again, and no negative experiences were reported. Patients were motivated to share their perspective of living with their condition in hopes that this would benefit other patients. Respondents felt that the course of illness was accurately portrayed, and all were satisfied with the balance between their own participation and the participation of their physician. Benefits to participation included the satisfaction of seeing many trainees and disciplines interested in learning about their condition and gaining additional perspective on their illness and medical decision making. Key themes are summarized in Table 1.

Final Program Evaluation

Residents

Twenty-one of 54 residents completed the survey (response rate 39%), with 9 PGY-2 (42% of respondents), 6 PGY-3 (29%), and 6 PGY-4 (29%) respondents. Residents attended on average 2.86 ± 1.15 of the 6 sessions; 7 residents attended 4 or 5 sessions, and zero residents attended all 6.

Resident responses regarding our series objectives are summarized in Figure 3. Ninety-one percent of residents agreed that they have a better understanding of the role of a neurologist in the outpatient setting as a result of this series. Ninety-one percent felt that they had a better understanding of patients' experiences living with chronic neurologic disease. Sixty-two percent agreed that they have a better understanding of what SDM entails. Additional responses are summarized in Figure 4. Notably, 95% of residents agreed the patients' perspectives added educational value. Fifty-five percent indicated that they have engaged in more SDM as a result of the series. Although only 10% reported that the series helped them narrow down their subspecialty choice, nearly half (48%) of residents indicated that the series increased their interest in outpatient neurology as a career.

• Download figure
• Open in new tab
• Download powerpoint

Figure 3 Program Success at Achieving Educational Objectives

Resident (R) (n = 21), faculty (F) (n = 6), and patient (P) (n = 6) perspectives on to what extent the outpatient series met its educational objectives of (a) improving residents' understanding of the roles and responsibilities of an outpatient neurologist; (b) sharing the patient's perspective on living with chronic neurologic disease; and (c) exposing residents to effective strategies for shared decision making.

• Download figure
• Open in new tab
• Download powerpoint

Figure 4 Additional Resident Survey Responses

Resident responses (n = 21) to additional survey questions about session learning topics and format for the final 2020 program.

Qualitative comments again indicated that residents enjoyed the session format and the opportunity to hear from both patients and their outpatient providers. The most commonly identified strength of the program remained the opportunity to learn from patients' perspectives. Table 3 describes the major themes identified from the formal program evaluation.

View this table:

• View inline
• View popup

Table 3

Major Themes From Qualitative Evaluation of Final Program (2020–21) and Select Illustrative Quotes

Desired topics for the future included neuro-oncology, use of DBS in Parkinson disease, ALS, sleep medicine, autonomic dysfunction and/or small fiber neuropathy, chronic pain syndromes, and neurorecovery after stroke or TBI. One resident expressed a preference that these sessions be conducted in person.

Faculty

All 6 faculty completed the survey. All agreed that the sessions met the 3 main objectives (Figure 3). All felt that having a patient present was essential to the session's success. Five reported spending less time preparing for the session compared with lecture, with one spending the same time.

In qualitative comments (Table 3), all faculty endorsed learning something new from their patient. They felt that the series allowed residents to understand the patients' perspective on illness and to appreciate the importance of the patient-clinician relationship for supporting SDM with patients. Both the preplanned outline of questions and having a moderator were highly valued. One faculty participant expressed a preference that these sessions be conducted in person.

Patients

Postsession interviews were completed for all 6 sessions—5 patients and the husband/caregiver for the patient with dementia. All participants agreed that the sessions met the 3 main objectives (Figure 3). All stated that they would participate again. None reported negative experiences, although the caregiver for the patient with dementia reported: “The only thing that made me uncomfortable is when [the patient] got more uncomfortable. She lives in the moment and she goes to her standard fallback responses.”

Qualitative responses indicated that patients found the format welcoming and comfortable. They appreciated having a moderator and an outline of questions to review ahead of time. Patients found it enjoyable and informative to review their case history; some found more clarity on their medical decisions after hearing about their medical journey a second time. They appreciated that this series emphasized the importance of SDM to reach informed, personalized decisions. Patients were motivated to participate to help others with their condition. One patient shared: “When we first met [my doctor], we made it very clear that any way we could to help out other people, we would do it, no matter how small. We want to expose people to this condition. We don't hide from it.” Patients modeled elements of good communication and moral standards in their comments (Table 3). We also found several unique benefits of participation for patients, including improved understanding, contribution, and hope.

Discussion and Lessons Learned

We implemented a novel, discussion-based, patient-centered outpatient neurology series that successfully educated residents about (1) outpatient disorders underrepresented in neurology training and the role of the outpatient neurologist, (2) the patient's perspective on living with chronic neurologic illness, and (3) strategies for outpatient SDM. The informal discussion-based format was preferred to and more engaging than traditional lectures, without requiring additional preparation time of faculty. Hearing patients' perspectives was considered essential and the most educational component by residents and faculty, and patients appreciated the opportunity to share their stories while learning more about their condition.

The structure of neurology residency training overemphasizes acute presentations of uncommon neurologic disorders and underemphasizes common disorders managed in the outpatient setting.^1,2 Nearly half (46%) of adult neurology residents report insufficient outpatient neurology exposure prior to making decisions about what fellowship to pursue.⁵ A survey of program directors (1994) suggested that residents should spend more time in outpatient neurology and that an ideal training program would include conferences specifically dedicated to outpatient management issues.⁴ An important implication of the success of our series is that discussion-based didactics may be an effective way to expose residents to outpatient neurology when an increase in clinical exposure is not feasible. Most of our residents reported a better understanding of the role of an outpatient neurologist, and nearly half reported increased interest in an outpatient career as a result of the series. These conferences alone are likely not sufficient to guide residents toward outpatient careers, as only 10% reported the series helped them narrow down their subspecialty choice. We also did not assess whether an increased number of graduating residents went on to actually choose outpatient careers. However, the addition of conferences like these into residents' didactic curriculum can serve as a concrete step to augment their experience with outpatient neurology. Furthermore, by choosing faculty participants based on their clinical and teaching expertise rather than research experience, our series also elevated clinician educators and those with outpatient careers as academic role models for residents.

Our series featured live patients partnering with their outpatient neurologists to teach about their lived experiences. Patients have been used previously in medical education interventions, with both learners and patients generally evaluating such programs positively.^6,-,8 However, the specific use of neurologic outpatients has not been well studied prior to our work. Previous research emphasizes the importance of selecting suitable patients: individuals who are articulate, not anxious, possess a good understanding of their illness, and able to cope if unpleasant issues are discussed.⁶ Selecting patients from diverse backgrounds can help ensure that a broad range of patient preferences and experiences are heard by residents. Challenges may arise when selecting patients with neurologic conditions, as a patient's memory, personality, or ability to communicate may be affected. During our session on early-onset Alzheimer disease, for example, our patient did not play as active a role in the discussion as her primary caregiver. However, this was true to the nature of this disease and illustrated the central role of caregivers in chronic, progressive neurologic illness. Feedback from our patients indicated that these sessions were neither a burden nor exploitative. Rather, this experience offered patients benefits similar to that reported previously,^9,10 including the opportunity to educate future providers, to help other patients with related conditions, and to learn more about medical decision making in their specific case.

We hoped that our series would increase residents' understanding about strategies for effective SDM. There are several reasons neurology residents may lack opportunities to practice SDM. SDM is less commonly used in the inpatient setting,¹¹ both because patients may be too ill to fully participate and because providers think SDM will take too much time. Residents are also more likely than practicing medical specialists to report a preference for paternalistic decision making when compared with SDM.¹² Lack of sufficient medical knowledge about outpatient disorders (e.g., prognosis, natural history, and treatment options) may serve as a further barrier to SDM.¹³ The format of our series is well suited to educate residents about SDM, as successful SDM requires bridging the expertise of the patient (their preferences, values, and lived experiences) with the expertise of the physician (options for treatment and the medical evidence behind each). Having both patient and neurologist present in the session allows residents to hear both perspectives and witness SDM recapitulated in real time.

Despite this, our results suggest that more work may be required to adequately train residents on SDM. Although most residents did report increased understanding of what SDM entails, fewer agreed that this objective was achieved compared with our other 2 objectives. Furthermore, only 55% reported engaging in more SDM in practice. Ultimately, SDM is a skill that requires deliberate practice to master; we hypothesize that fewer residents reported this objective being met as our series did not offer residents an opportunity to practice this skill themselves. Perhaps pairing our series, which offers specific knowledge about SDM, with hands-on sessions that offer residents an opportunity to practice SDM skills^14,15 would better achieve the aim of increasing residents' use of SDM.

Our series highlighted communication skills that residents must master to become expert outpatient neurologists. Patient-centered care is often idealized in medical education but is typically defined and taught by physicians.^16,17 Our series allowed patients to articulate best practices for patient-centered care themselves, highlighting the most effective physician behaviors and communication skills. Our patients hoped that sharing their experiences would teach residents effective means to deliver difficult news, explain diagnoses, and/or instill hope. Positive role modeling by doctors is important in the professionalization of medical trainees¹⁸ and can promote learners' development of communication and character skills.¹⁹ Less is known about whether patients may serve as a kind of moral exemplar for character development.²⁰ Patient-led seminar series like ours may fill a void in trainee education and professional development by focusing on emotional, communication, and moral issues.²¹

Our series reaffirmed the need for and importance of augmenting education in outpatient neurology and offered several lessons learned. The topics we chose—while common conditions in outpatient practice—were indeed underrepresented in our residents' training, with only one-fifth of residents following more than 1 patient with a similar condition in their own clinic. The format of our series was essential to its success, as the most beneficial aspect of the series was the ability to hear the patients' perspective directly. Feedback obtained from our pilot series allowed us to refine the session format; to aid those planning to implement a similar series elsewhere, we summarize the best practices we developed in Table 2. Key practices included having a moderator and preparing an outline of questions for patients and faculty beforehand. This ensured that patients were comfortable with the planned discussion topics (we could confirm, for example, that a patient was willing to discuss end-of-life planning) and naturally helped balance the patient and faculty perspectives ahead of time. Our transition to a virtual format as a result of the COVID-19 pandemic did not diminish the educational value of the series and was convenient for patients, faculty, and residents.

A limitation of our findings is that our series was implemented in a single residency program in an urban, academic medical setting. Local implementation and assessment of similar programs elsewhere is necessary to ensure that it meets the needs of residents in other programs. Another limitation is that each session is unique to the featured patient and provider and thus difficult to replicate. Cross-institutional sessions could be trialed to broaden the reach of this program, while leveraging the success of the virtual format. This may be an important option for programs without access to outpatient faculty in certain subspecialties. Nevertheless, we have identified key programmatic elements that can facilitate independent adaptation elsewhere. The success of the program will ultimately rest on knowledgeable faculty, articulate patients, and a well-practiced moderator.

It is possible that responder bias may have influenced our results, as residents already interested in outpatient neurology may have been likely to respond to our survey. Self-report of behavioral change is further prone to recall and social desirability biases. Future work is needed to determine whether residents' self-rated increase in knowledge translates into behavior change. Finally, we hope that the success of this program may encourage neurology educators to consider how else to incorporate patients into curricula more broadly. At minimum, in future sessions, we plan to allow patients to take a more direct role in identifying desired learning objectives for these sessions before the moderator generates an outline. We can also imagine patients playing a role in teaching or evaluating communication skills or giving feedback on SDM in a standardized OSCE.

We implemented a feasible, low-resource, and impactful educational series highlighting outpatient neurology disease management and patient-centered SDM. Our session met important objectives not currently addressed in most inpatient-heavy neurology residencies and was of interest and benefit to neurology trainees, faculty, and patients alike. Future work includes evaluating the long-term effect of this series on residents, including their understanding of SDM, the role of the outpatient neurologist, and career interests in outpatient neurology.