Episode 9: Conscious Competence with Vijay Ganesh, MD, PhD

As academic schedules turnover in July, it's the perfect time to return back to the basics of bedside teaching. On this episode, I speak with Vijay Ganesh, MD, PhD, Assistant Professor of Neurology at Harvard Medical School, a neuromuscular and neurogenetics physician-scientist at MGB and the Broad Institute, and two-time winner of our local excellence in clinical teaching award. We discuss how rehearsal behind the scenes makes "on the fly" clinical teaching effective, balancing the right measure of expertise and curiosity at the bedside, and the practice of cultivating "conscious competence" as we role-model for our learners.

Neuropraxis: The Neurology Educator's Podcast is not recorded as an official podcast of any institution or organization. The views and opinions are those of the individual speakers themselves. Music from Pixabay. Cover art by Carolin Wollny. Editing by Valeria Roldan. New episodes drop first Monday of the month!

Ideas, suggestions, questions? Contact us at neuropraxispodcast@gmail.com. 

Transcript

SPEAKER_00 0:02

Hello and welcome to Neuropraxis, a podcast for clinician educators and trainees passionate about neurology education. I'm your host, Gelena Gatman. I'm a neurologist and medical educator. On the Neuropraxis Podcast, we turn our attention to neurology education. We discuss the latest topics in education literature, meet the innovators shaping the future of neurology education, and hear about the career journeys of other educators in neurology. Whether you're building a career in medical education or looking for inspiration in your teaching, you're part of our community. So let's reflect and grow together as we blend the art and science of neurology education and put theory into praxis. Today I speak with BJ Ganesh, a neuromuscular specialist at Mass General Brigham and a physician scientist at the Broad Institute. We speak about the importance of rehearsing for the show that is bedside teaching, the balance between expertise and curiosity, and the importance of upcultivating not just expertise, but conscious expertise. Vijay is a physician scientist. He spends most of his time at the Broad Institute, where his research focuses on developing methods to improve the diagnosis and discovery of genes that cause rare neurological diseases. But despite claiming to be mostly a physician scientist, he is nonetheless the winner, two-time winner, of our inpatient teaching award. And so I really was really excited to invite Vijay on the podcast to really take us back to the bedside and take us back to some of the fundamental skills of a neurology educator, and that is teaching. So Vijay, welcome.

SPEAKER_01 2:46

Thank you so much, Galina. It's a pleasure to be here.

SPEAKER_00 2:49

I'm really excited to talk with you, Vijay, because you may or may not know this, but when I think about one of the best educators that I had in my experience as a medical student when I was on the neurology wards, it was in fact you. You were my senior resident in the neuroICU. You may not even remember this because it was, you know, nights for you. And there you were, little paper in hand, teaching us about ventilator dynamics. And I remember thinking, what? This guy knows how to control a ventilator and he knows neurology. So for me, you'll always be that image of you with a little, you know, at the time paper, now you have an iPad. Um and so I, you know, I'm so excited to invite you back and to learn a little bit about how you think about teaching to learners in the clinical setting and you know how that differs from other settings in which we teach.

SPEAKER_01 3:36

Oh thanks, Celina. I I I do remember our time in several uh times we overlapped, and your enthusiasm for neurology was it's infectious. I think that part of teaching for me at least is seeing that sort of aha moment. Um and yeah, you definitely had it, but yeah, now I'm embarrassed to think what I might have been saying for ventilator dynamics. It's like you know, you always don't know if you're overstating your own expertise, but um I appreciate the story.

SPEAKER_00 4:01

So, Vijay, you teach in many different settings. You teach some of our didactic to the clerkship students, of course, you uh rotate on the wards and supervise residents there. So, talk to me a little bit about how you think about approaching teaching in the clinical setting and especially in that kind of more bedside, uh bedside situation.

SPEAKER_01 4:21

Yeah, I zooming out for me because you know not unlike a lot of people in academic medicine, like I, you know, I I have multiple roles. Yeah, you know, and so it was a kind of a conscious decision in choosing to maintain some of my life um in my professional life in in medical education on the wards was how to how to focus that attention. And I think for me, like most of the appeal is to transmit this knowledge almost like apprentice style. I think you like for me, it's like kind of a principle. You don't at least for me, I don't think I could have learned neurology without that sort of direct, you know, uh mentor to student relationship. It could not have been learned in the abstract. And I for me it's like a continuation of that. It's an ongoing kind of challenge, which is how to be effective at that. But for me, like the heart of it really is that sort of instantaneous moment at the bedside, not abstracted with a patient there, and you're distilling some you know essential fact um or a technique, uh or sometimes both at the same time. So that was where the sort of the the like my focus started from. And how to get better at it is like kind of an ongoing work and process for me.

SPEAKER_00 5:40

You mentioned the idea of apprenticeship, so that involves really being in the workplace setting, as you mentioned. It's not doing it in another setting, it's doing it right where the work where the work is done. And it often involves a role model or a mentor. Is that something that you saw role model to you in your training? Is that were there people who you in whose tracks you're kind of following as you do this work?

SPEAKER_01 6:04

No question. I think like the origin of my interest in neurology, I mean, I think like a lot of other people, it's sort of like, oh, you're fascinated by the brain, how could you not be? Um, and it's sort of mysteries. And and so for me, my interest in neuroscience broadly started with that, with the extra sort of spice to it, I guess you could say, of that, you know, the brain is built like every other organ on on the on from genes. And so my initial sort of key really foundational mentor was Chris Walsh, um, who is a physician scientist who trained in our the same program we uh we trained in. And but his emphasis was really at the sort of intersection of genetics and and how genes informed the development of the brain. It wasn't until I started on the wards uh and you know, had first exposures as a medical as a as an undergraduate with Vern Cavanus, uh, who's also physician scientist, but it was a matter to me because you could see the bridge to like his effectiveness really at the bedside, where I thought, like, this is a completely different domain of skill. Like, I, you know, we the one thing to sort of understand the brain, but now you're faced with like a real problem. And there were there's like it was just it was a brief kind of you know experience working with with Vern, but it was really foundational to my to my kind of early motivation to feel like that should be part of of like you know my my career. But then once I started in residency, the key mentors were at like across multiple sort of stages of seniority, where like the immediate senior residents, uh, and were you know, Aaron Berkowitz was uh very foundational uh to me, just inspiring as someone who's effective at the butt side, a really great communicator, and just I mean, like polymath level of expertise that spanned beyond neurology, to be honest. I don't know, um, you know, it's just great to stumble into people like that once in a while. Tracy Milligan was the clerkship director, um, and also like for me very inspiring as someone who kind of emphasized that you can do these other things and still be, you know, have teaching be part of your life. And then of course, how could you not that if you were overlapped at all in that era with Marty Samuels and Alan Roper? So really it was kind of these like multiple generations of of teachers or clinical educators, but who were highly influential to me and still are, you know, even though they're you know it's not like I see them uh it they're just sort of in my mind, and I'm I'm you know truly kind of channeling them almost sometimes explicitly and even the language that I use uh for distilling key points or you know, uh yeah, it's it's they're I feel like part of me is uh kind of components taken from them.

SPEAKER_00 8:41

So I've had a chance to witness that, but for those who are listening, can you give us a little bit of an example? Like can you specify a specific element that you teach in a particular way, or if you can recall like a very kind of specific example of what you saw them do?

SPEAKER_01 9:00

Well, I guess start with Marty. Uh he would, I mean, this seems so foreign as a kind of a neurology chair that would teach to some like well a big part of what inspires me about Marty, and I still do is like I think like I'm a subspecialist by necessity in the you know in the academic environment, then there's a sort of professional incentives to sort of go be even more narrowly defined, you know. So I'm a neuromuscular you know, uh uh trained neurologist, and within that, sort of interested in genetics, and even within that, maybe more into like muscle genetics, it gets like absurdly narrow. But then you zoom out and you realize like Marty just gave a he's the chair of the department and can give you like completely extemporaneous 45 minutes on dizziness. And I think with some intentionality there, right? Like he has uh we you've eventually you hear it so many times that it becomes like, oh, there's Marty going off again on dizziness. But like that's something really intentional that he's like, no, I'm gonna have my focus be on this, like a topic that is but definitionally general, like there is like, you know, it would be absurd to be sort of the dizziness subspecialist in the neurology department, but you have to have an approach to that problem. That's what patients present with. And to have that topic be not mundane, but in fact quite compelling in the way he tells it, is just a very good lesson, I think, and how to both the sort of a philosophy of teaching, which is like don't start with the esoteric, start something with broad, with relevance outside of your profession, um, to regular people and regular doctors, and to make it compelling and but not just performative, like that there was real teeth to those lessons, like how to approach it with discrete moves, examination maneuvers, approach to the history. And you know, you're left with it. It it's something like that a lecture with you stays with you. Yeah, he gave it multiple times, and you, if you were lucky enough to hear it, you want you saw the moves ahead of time. Masterclass in both the uh the distillation of a teaching point, but also like topic selection, right? And I try to stay as much as possible, uh I try to maintain some hooks to general top approach to a general problem, even though, again, it's intention with again the academic incentives to become like super narrow into some sort of X, you know, become an expert in some isolated thing.

SPEAKER_00 11:20

I'm so glad you brought up Marty, because I I do agree with you that once you've heard the lecture a couple times, it was like watching your favorite movie again, you know, like you knew the parts, but you you still wanted to watch it. But I think Vijay, you actually articulated some really good points that I want to pull up at a higher level. And the first is that if you want to uh teach to an audience that's kind of more general and have an interest from everyone, choosing general topics that will be of interest to most people is a good idea. And so thinking about like teaching to the students and to the different learners, you're gonna bring most people in if you can think of a topic that will be relevant to them in some way. I think the other thing that you're hinting at is this idea of a fine balance between like rehearsal and opportunism. So, in the sense that you know the patient in front of you you may not know what's coming in that day, but if you have a few ready topics, then when disease comes, you know what to say. When you know uh weakness comes, you know what to say. And so I'm curious if you could talk a little bit about that behind the scenes work, because I do know that you have some set, maybe maybe not lectures, maybe let's call them you know chunked topics, and you've also developed some infographics to go with that. And so I love would love to peel the curtain behind the scenes for how you decided to do that, if you decide to do that, and and how you've developed those and incur incre integrated them in your practice.

SPEAKER_01 12:44

I think it wasn't an intentional thing. I think um I I might be misstating who first sort of inspired me to do this, but I think when uh Tracy Milligan was my attending, and you know, it's sort of getting feedback at the end of your rotation, and uh she was like, you know, we start to work on uh various levels of framing you're teaching. You have, and it might have been Aaron Burkowitz or Tracy Milligan or a combination, that said, like, you know, have like the one-minute lesson on this topic, and then have the five-minute version, and then the 15-minute version, and then eventually maybe the 45-minute lecture-based version. So that was helpful, which is like how do you frame not just to the audience, but how do you make something salient with different timescales? And so that sort of what started the genesis of like a few topics. So uh I think when I was at first uh, you know, my first year as an attending, I thought like, oh, let me teach to the really fascinating subjects. Let's let me just have a talk on like CNS vasculitis. And I think part of it's like Aaron Berkowitz had, I recall, like a pretty good like lecture on that. Uh not pretty good, very good. But uh, and so I thought to kind of mimic that kind of thing, like, oh, like or what are what are approaches to autoimmune encephalitis? I it didn't take long before I realized I should jettison that and focus on kind of the more, I don't know, Marty end of the spectrum to be like, no, let's talk about like weakness. Let's have an approach to like how you just examine patients or even approach the general problem of weakness, or how do you approach encephalopathy? So that's how it sort of started like, well, you have to be able to teach that at multiple timescales. And then what came into play was making graphics, which I don't think that there was one person who taught me that. This sort of came from honestly, maybe my more my PhD experience, where I just was really impressed by people who could visually display information elegantly in in papers um and in lab lab meetings, things like that. And so, like Edward Tuftee, you know, the professor at Yale's like you know, visual display of quantitative information, other things like that. Like that's just been in the background for me, like how to just be effective in t in visually showing things. So that's sort of what started my sort of infographics, if that's what you're talking about, um, which I only really distribute locally. I don't I think they're only effective if paired with like kind of the immediacy of a bedside examination or bedside lesson. So I haven't really, you know, I use it only to sort of enhance the lessons for like the students' retrospective look in the hopes that something visual after the fact might anchor the lesson that can sometimes be fleeting at the bedside.

SPEAKER_00 15:20

Well, you are enacting one of the key principles of UDL or Universal Design for Learning, which is this idea of multiple modes of representation and engagement that allow the learner to kind of take the information in the way they prefer. And so I actually think that's partially why your lessons are so effective and memorable, is because some people will remember the oral version and some people will look at the sheet, like the visual graphics, and some may get excited and go back and read more and start to solidify the that framework for themselves.

SPEAKER_01 15:52

Yeah, and your point about like sort of how much of this is like sort of rehearsed versus extemporaneous, it's a challenge, I think, maybe because of just initial internal anxieties about making sure I was effective on the words. Because when you're starting, you just don't know. At least I'm like, I'm like, I'm not I only get the privilege of doing a few weeks a year, and I want to make sure that that's both and uh you know salient to the students, but that also like it's something that professionally develops me too. So I did sort of outright rehearse, you know, like to myself, like, can I do a 15-minute version of this topic? Uh and so it did have some iteration, and then that that was I think necessary. So some of those topics that I've now iterated on a few times, like they do come a little bit more automatically, I guess, like because you just remember the moves, but then there's always like a little extra version that you can update, you know, each time you either give it verbally or the or the graphics and things like that. So that part's true. There's still something to be said about the extemporaneous aspects, like something you didn't expect, and you just have a, you know, a nugget here and there. But for me, now most of those are sort of hypothesis generating. It's sort of at the bedside, it's like, why is this happening? Like something absolutely bizarre that you see, and it's less maybe about the lesson and more about the observation. It's like, did you see that? You know? Um, how do we think about that? And it's more, hopefully that engages. I think to me, one of the most amazing things about neurologists, historically at least, is that the absolute level of attention to things that don't seem immediately relevant, you know, but are tied together, like Babinsky noticing, you know, um eponymous sign or PSP and like up gaze, down gaze restrict. Like these are just crazy observations that I think that it's important to sort of have that culture. Um, and so a lot of the more extemporaneous things for me on the wards are mostly about this, like something that doesn't fit. And it's like, wasn't isn't that wild? And then yeah, most of the other things I think are these like short short form, admittedly rehearsed topics that uh hopefully get more polished over time.

SPEAKER_00 17:54

I'm glad you mentioned the rehearsal. I think it will be helpful for others out there who are wanting to be educators to hear that there is an element of rehearsal. To me, it reminds me of any other training for expertise. You know, if a basketball player wants to score on the field like they're doing drills in the background, and I think that shows your level of dedication to development as an educator. I think so much of what we see are these superb kind of senior educators, it seems like, oh, they're writing on talent and knowledge alone. And they they probably are bringing a talent and natural enthusiasm, but also there's that rehearsal in the background. So I appreciate you sharing that. And I also liked what you said about the attention and the observations because I think there's that balance, right, between expertise and curiosity. And when I think of the people who I found to be most compelling as role models for me, it was the person who seemed to know everything and in the very next case would say, Wow, that's fascinating, I've never seen that before. And you know, Marty used to do that, and you you do that as well when when we rotate with you, and uh just like I love that idea of that you it's seemingly um maybe paradoxical to have both the deep expertise and like the humility and curiosity of something new.

SPEAKER_01 19:13

It's what makes the job so to me, continually renewing as you know, yeah, keeping attention and focus. I mean, it's just I that is if we don't engage with that, the job can become, I think, a bit rote, right? I mean, like you could have a quit pretty cynical view of what we do and say, well, I'll just order the MRI, the EEG, and then get an LP once in a while. And then that becomes operational, and then you lose a bit of the this extra element of like engaging with the unknown. Like even the things that are like, you know, like garden variety, bread and butter, like, you know, whatever. Like I just finished a week on consult service. It's like, you know, over a third of the consults are some version of an encephalopathy that's you know, a generalized process that wasn't, we didn't add necessarily too much value to tell them that. But it is a bit wild, right? Like the EEG is like, there is all this slowing, and yet the organ is like kind of mostly working. Like at some level, we need to kind of come to terms with that. But we just sort of like, oh, like next consult, that's toxic metabolic encephalopathy, move on. But uh, you know, it's worthy to just pause once in a while and be like, this is kind of wild that this is engineered to be relatively tolerant of a lot of nonsense and still mostly function. Uh and you know, that it's that kind of stuff that I think for me just keeps it still like kind of fresh, even though you can still teach to like, yes, this is a toxic metabolic encephalopathy next case. And then that's fine in that moment to acknowledge.

SPEAKER_00 20:43

Yeah, no, I I think you're right. I think we we have a certain level of humor also um in neurology that keeps us going through the day.

SPEAKER_01 20:51

Oh, it's so necessary. Again, like part of the inspirational effects of people, like if you were ever in the orbit of Marty, you know, again, it's just like I can I can go off on how much the I can't imagine now with just the culture of who we generally see as like, you know, leaders, they're tenor generally sort of, you know, humorless. You know, there's this maybe a selection against that. His humor tended to be a little bit more provocative, maybe it was of the generation where that was maybe like more tolerated. But it is like it's just way more fun when it's a little bit funny. Um, and you can't you can't sort of take that in too far in the wrong direction, but it's so um, it's just so memorable when you you compare it with a little bit of silliness, you know. I don't I think there's a there is a there is a path to being like a little bit silly and still sort of professional and respectful for the patient's experience. I don't think that those are incompatible goals, but I do that see that rat gradually being eroded from what's you know considered, you know uh among leaders in you know the field.

SPEAKER_00 21:56

Yeah, well, at least among educators, it's definitely still. Loud or so uh you know public service announcement, feel free to inject a little a little bit of silliness. I wanted to go back to what you were saying about rehearsing on your own and trying to prepare for that first delivery. And I'm curious, have you had the chance as an educator to get feedback from others? Like, of course, we get feedback, you know, from the faces of the students, how how many of the blank stares have converted to some some level of understanding? Yeah. But have you had other ways to get feedback on your teaching? Is that something you've sought or been able to get?

SPEAKER_01 22:35

I'd say I eagerly seek it. I don't know if I receive it. I think that it's just it's a lonier experience as an attending in you know, and I think most of what I sort of get is exactly what you described, that sort of valence of oh, I see a certain drop in attention in this room right now. And that's actually pretty helpful. To me, I kind of that helped a lot of the iteration of the things that I try to teach to. But as much as possible, I wish I got I wish I could get more feedback from maybe fellow attendings. But I think that would require more structure, like somebody else who's actually physically there. You know, like someone like kind of a coach kind of shadowing you on rounds. I know there's been some models of that, but that to me is affectative. I think honestly, some senior residents is you get to know them like like you were for when we work together. It's like you've known this person now across, you know, their first year of residency in neurology, second, now third year, and you're at the level of a colleague. And I think that's the closest I think I've gotten where it's like, no, this person can really sort of redirect you a little bit to say, yeah, like tone this down a bit, or you know, we ramp this part up. And that is it's honestly the senior residents that I think have given me the most actionable feedback. Uh, but yeah, I would like I think like that sort of intermediate tier faculty like uh uh level feedback would be super helpful, but I think for them it's hard because they're just not in the room when the stuff that you want feedback on is is is expressed.

SPEAKER_00 24:03

I agree with you. It's challenging to get that feedback the further out we go. Are there examples of things you've changed based on feedback?

SPEAKER_01 24:11

I well, it's easy to say many things, but I think for me, uh the I think the best uh feedback I've gotten is mostly uh uh on like what to change is you know, I used to send like pretty long-winded emails of teaching topics initially when I was a junior faculty, and I and I thought that this would be like oh mostly for retrospection. This you know, students and residents can sort of look at that. And I've over time sort of de-emphasized that and have the the topics be if it's gonna be salient, it should be salient in the moment. And like those like one-page graphics that I send maybe the only thing I email now for the most part. Every once in a while I'll be like, no, this case is worthy of some sort of deeper dive, and I'll send some email with no real intention that that's gonna be. It's mostly for my own posterity, to be honest. But I do send it out to the team just to be like, oh, like this, you know, if this is helpful to you and how I'm thinking about it, it you know, you can, you know, roll with it. But if for that that's it, so I feedback that I honestly got from senior residents was a maybe a little less sort of email on the teaching points and more have it be present. And I honestly I think I agree with that. I that's what my own learning was prefer preferably that way too.

SPEAKER_00 25:24

I like that feedback. It goes into a little element of like situational awareness, you know, like in the sense that you think, oh, my email they can read at their own pace, but at the same time it becomes this additional thing that they didn't get to at the end of the day.

SPEAKER_01 25:37

Oh, sorry, Galina. Yeah, that's the other topic feedback was I'm just really thinking, probably the biggest change actually in my own behavior is I used to teach a lot to like, well, here's how I think a note should be written. When I would read like either the medical student or even the resident notes, I'd be like, you know, I would I like I would make it a little bit more explicit of like a topic to bring up during feedback or even like to walk them through some comments there. And now I honestly don't I hope to write my attestations in a way that distills how I want notes to be written. That it's more like I think if there's something like that I can say is I'm condensing this and putting it in a note, that I'm that's my passive form of teaching to that topic. That I initially had made a little bit more explicit as like a teaching point. But in the interest of time now, I'm just sort of like, well, yeah, if you read enough of how I'm writing my note, then hopefully the lesson will be received. But you know, a lot of what is put in these notes is totally unnecessary and often distracting. And that's a lesson I don't even I'm hoping is passively received.

SPEAKER_00 26:35

Yeah, so I mean that's another point about role modeling. And I think that that is I think we don't emphasize enough how much is learned through behavior, and that includes like passively observed and as you said, sending the signal that you you prefer it a certain way or that you've done it a certain way. I was curious if you think about teaching different learners differently. So you talked about at the start that you know a general topic's gonna bring all the all the heads, it's gonna turn all the heads in your direction. And on the wards, we have a balance between the medical students and primarily the junior residents, maybe the senior resident. You also uh are one of our neuromuscular specialists and um one of our you know favorite EMG attendings. And I'm curious how you think about teaching fellows, or for example, teaching a procedural skill like EMG or the neurological exam. Do you approach those different um categories of learners, categories of teaching differently?

SPEAKER_01 27:31

Both the fun of it and enormous challenge. I think I I think everyone naturally slots into probably their sort of sweet spot of who their audience that they can teach to with more, I don't know, either vigor or enthusiasm. And I'll admit that sort of the the the audience that I I think reach the best are sort of that super enthusiastic, like people who are really love it, neurologists at their sort of you know, early stage of their residency. And I think like it's very mutual, like you sort of get it when that resident is sort of both appreciates and is giving you that sort of valence of like wow, like this is you've like opened my eyes to something. It's a similar feeling that I I remember in now in hindsight of like, oh my gosh, like my that like chemistry professor in high school, uh, or my calculus teacher, like they just taught me something that I totally didn't get, and now I have that sort of moment. And it it it is an external, you feel something is externally expressed that way, just like a look. Um, or that look when you're on the wards, you've you've had this where you're like you see the resident making the moves on the exam, or even their questions, and you're like, oh yeah, I know what they're thinking. And then you know, it's just this this it's this sort of neurology moment that like you're kind of telepathically linked to this person. It's uh it's uh it's a really nice feeling, and I think that type of learner I really feel drawn to to sort of distill even more um you know, skill, information, nuance, um, and that comes a little bit more automatically. Where it but I think to be effective, you have to be able to sort of reach someone who's maybe not in that zone yet, and it's like sort of the medicine rotator or the psych rotator or the medical student who's like maybe not honestly even that particularly interested in going into neurology. So that I've tried to over time try to make appeals to that type of learner too. And I think I've gotten a little bit better at it, but it is a bit of meeting them where they are and trying to give topics that you feel will have broad applicability for them. Um and that that's sort of my where I where I shift. So most of my lessons there are again on these more fundamental topics, like how do you approach weakness, how do you approach a mental status examination, um, you know, how do you approach an acute chief complaint, you know, something like acute monocular vision loss or something. And then I found that I've um it's worked. I think I get like, oh yeah, this is a topical thing for me, and you get the attention um back. Not necessarily that sort of existential, like, wow, this is some awe-inspiring thing, but you get like the sense that you've you've reached them.

SPEAKER_00 30:13

No, I love that. I've never really thought about like the idea of like joining in on like a mutual floating. It's happening. Every once in a while in that learner. I know you mean.

SPEAKER_01 30:23

Yeah, I don't this sounds maybe way too like, you know, uh maybe we're hyping a thing. But I yeah, I think we've had moments like that, you know, and I I it's it's it's it's fleeting, but I do think that there's there's something about that that adds a um a camaraderie element to the journey in neurology, which for the most part is a sort of solitary experience, but it's certainly outpatient it feels that way. Um, but on the words, every once in a while I can sort of feel like, you know, they're not just that like we're in this together, but like that person is getting it. You know, it's like the feeling, you know, when like my daughter is like gets a new skill, it's like, whoa, that is some like synapse has been formed. And is like, you know, it's like something actually happened there. And that's like a really rewarding feeling seeing it in someone else because you were once there, right? We all kind of if you're in the field, you were like, I know kind of where I was when I first saw like neglect, right? Um, and then you like you only have to see that like two or three more times before you're like, oh yeah, that's just neglect. Kind of it's like a it it it fades. So do you want to be there at the origin of it for somebody else? I don't know, it's just like a really special feeling to be there.

SPEAKER_00 31:32

You put that so beautifully, because at the start you had said like it's rejuvenating, and when people ask me why I like to work with learners, it's because I get to see neurology through their eyes. And you're totally right, I get to join their synaptic moments of insight. That is not as common for me anymore, uh, at least with the bread and butter cases. Um, I love that.

SPEAKER_01 31:57

But to I I got off topic there, but to for your question about like procedural learning teaching to fellows, it it does, it totally does change, I think. You know, for you for you're adding a little bit more depth each uh of learning each time you go one step up in learning. So if like for the fellows, it's like, yeah, yeah, the fellow gets it. This is a myopathy. Um, and you were like, well, what's the extra sort of consideration here? Um, you know, sometimes it's a more of at that point, like a very deeper dive into evidence-based management for the, you know, diagnosis is pretty clear, sort of how do we know what to do here is not just like stylistic, but actually has some teeth behind it. An area, to be honest, that I think is a little bit underdeveloped at the residency level, where we are teaching mostly to the phenomenon for a long time and then teaching sometimes to management, but just mostly like here are the things we do, not necessarily like the level of evidence that justifies that decision. So at the fellows, I sort of shift more gears into that, which is like kind of peeling back the onion a little bit to say, like, actually, yeah, we do this, but oh by the way, it's actually not that based on evidence. Um, so like just to acknowledge that reality. Um, and then the procedural stuff, like learning EMGs, is not unlike learning like the reflex examination. You just want to at least be there so that they initially develop the good habit, acknowledging that it's only going to get better if they iterate on it. But at least you can make sure that there's not like some major error in the initial method, you know. But it's like, you know, I play tennis and it's like uh I I want to have my form be taught, be observed, and improved by somebody else, but at the end of the day, I still have to hit a thousand backhands to have that skill ever get anywhere reasonably close to proficient.

SPEAKER_00 33:38

Yeah, I do like your thinking about the fellow approach and what they need. I heard a nice little slogan which is like in residency you learn what to do, and in fellowship you learn why we do what we do. Um and then I guess as an attendant you decide if you want to do what we do. Um I also think that it can be hard if you're not pitching to the right level. It's the same idea as like you could lose, you know, junior junior residents if it's kind of goes over the head if it's too complex, but you could also lose fellows if it's not complex enough or if it's not adding to where they're at. And then each fellow, I presume, will have a slightly different level of understanding. And so there does give you that one-on-one time to figure out like where they're at and actually match match what you're training to their their next level of development.

SPEAKER_01 34:27

This is the hardest part. I think you're you know you're like someone's ready to sort of launch and be like independent. And it might be the last chance you're getting the sort of direct supervisory rule. They're they're also kind of protected by the umbrella of an attending, and you want to kind of develop the autonomy at that stage a little bit more rather than just like, oh, like, just do execute these things. Um and yeah, the the the the fellow training is I think a little bit more crucial for that. It it it's so different, I think, the medical student level that um I I've had to zoom out a little bit sometimes to be like, no, for this person, it's you're almost talking something a little bit more you're going super deep into a particular topic, and and um and it's uh it's sometimes there, it's like there's not like an infographic or something that I can point to. Um you wish you could, but it's it's uh it's uh it's like a very situational kind of lesson that you're sometimes teaching.

SPEAKER_00 35:16

Yeah, I was reading a book on expertise development and how it can actually be quite challenging to articulate what you know. And sometimes just to I feel like we're kind of circling around this idea of apprenticeship, there are some areas of um of expertise development where there is still no verbal manual, there's just action and a correction of feedback by the expert, like yes, no, yes, no, yes, no, that develops implicit expertise. And I sometimes was thinking about this, I was reading this book and I was thinking about how sometimes I walk in the room and you know I'm hearing the story from the resident, and this is on precepting clinic, and I'm kind of like not fully getting the picture, and then I walk in and somehow, somehow, about what the patient says the second time or the way I'm doing the exam, I'm just like, oh, I know what this is, and then trying to like reflect back on how did I get there? How do I explain that? And how do I persuade the resident? Sometimes they'll ask me a question, and suddenly I'm like, wait, I'm confused. Am I certain? And it's really not a gap of knowledge. It's actually a gap between implicit knowledge and explicit knowledge, which can actually occur even at high levels of expertise. I don't know if you've had that experience.

SPEAKER_01 36:27

I totally agree with this challenge. And I wish I was in this area of whatever branch of science this is, you know, sort of some sort of cognitive neuroscience or whatever. But I am like, I am uh uh have a very superficial understanding of, but I'm interested in it. I think it was like Noel Birch wrote this, you know, like the framing of like levels of how you develop knowledge, and it starts off as sort of unconscious incompetence, like you don't even really know you don't know a thing, and then it evolves like you're like then consciously incompetent. Then that's a struggle, but at least you kind of know what you don't know. And then eventually the experts become, and I dread it at some level, like becoming unconsciously competent. Like you're actually pretty good. I know people like this, you know, like you like, but they're you like you would send them a patient or something or in information for like a second opinion, and then they're like, oh, it's just this. And it's like it's so implicit for them. But then you ask them to sort of, you know, replay the moves so that you actually get something out of that that you might be able to yearn. And then and they totally fail at that. Like they're kind of unable. And so, and it's not like a it maybe that is what like true expertise needs to be. It needs to completely escape conscious awareness and that it just becomes this sort of you know automatic thing, and that's when it's the best. But I'm at this stage, probably here, like sort of you know, early, mid-career, whatever, where I'm sort of consciously competent, which might make me more effective as a teacher, because I'm not yet reached that sort of zen of unconscious competence. Like I kind of know the moves right now, of like and all I know what I didn't once know, which is helpful. And I think that's use that's uh I'm kind of lucky that I'm sort of still there, uh, because maybe that'll escape me at some point, you know, along the trajectory. So it's sort of like it is this metacognitive effort when I'm teaching something, which is like, oh, like, well, what were the moves? Like, what did I not know? It it's not that difficult for me yet, but I mean, just based on who I admire, that totally can't do that right now. You feel like I've that's that's a uh a stage that you might not always be in.

SPEAKER_00 38:31

Uh I think I've had the even scarier experience where someone will ask me something and I won't have a conscious understanding, but nonetheless, I'll start talking because you know you can't just stare dumbfounded, and then what will come out will sound really competent. And I was like, where did that come from? That makes total sense. I was explaining to a patient with like who had a uh you know a certain condition and a certain risk factors, and he asked me a very blatant good question, and I was like, right, you we can't do this because this leads to this, leads to this, and as I simplified it, I was like almost for the first time understanding it by myself. Like I because I think it was that element of you know, as a resident, I had just done stuff, like I knew we couldn't give him one medication, but when he asked me why, I had never really articulated it, and in doing so, I learned something myself.

SPEAKER_01 39:23

Well, that's good that it's sort of sort of in the in sort of then deliberatively more than explicit, but it wasn't before.

SPEAKER_00 39:31

It had never been.

SPEAKER_01 39:32

The fact he contended that, yeah, I think that's a good exercise, actually. I mean, I I think it's like I'm I think forcing yourself to do that actually periodically might actually maintain this sort of conscious stage. Uh I don't know. Again, someone's probably thought more deeply about these things, undoubtedly, that we're I'm just sort of stumbling into. Well, talking about right now.

SPEAKER_00 39:52

Disagree with metacognition and this idea of thinking about your own thinking and self-reflective practice. That's definitely key to improving both as a neurologist and as an educator. So at the very least, we can say that's for sure.

SPEAKER_01 40:06

But not in everything. Like again, back to the tennis thing, because I mean I really like it and I struggle with it. But it's like when I start thinking about my serve, it objectively gets worse. Um, and so I don't really want to apply that metacognitive effort to really everything. But as it relates to like teaching medicine or even being sure in your own diagnoses, I don't know yet. I'm unsure if the one way is better or not. I mean, again, Marty, I'm citing Marty a lot here, but uh, how could I not? I mean, he I think was also interested in this, like how we think, you know, uh uh problem. And, you know, he would cite Kahneman a lot about, you know, this thinking fast, thinking slow paradigm. And it's like it gets it ties into this concept, but it I don't uh, you know, we mean you use both modes of thinking to really be effective ultimately, which you know sounds right, but then in practice becomes a bit like, well, how do we implement that? You know, like it's not really straightforward.

SPEAKER_00 41:02

Um, I'm so enjoying this conversation, Vijay, because one of the questions that we've anticipated and had a nice segue was what are the challenges of bedside teaching? And you know, when I first was thinking about this, I thought, you know, the usual stuff, right? Like there's no time, the patient's sick, you have to focus on that, maybe the learners are scattered. But what an interesting insight to bring, which is the um the implicit to explicit cognitive gap. That is not something I anticipated that we'd be bringing to the list of challenges.

SPEAKER_01 41:37

Yeah, yeah, it's the curse of knowledge problem. I mean, I've it there's there's things written about this. I forget the initial authors who coined that term, but it is this challenge. Like the people you want to learn from are the people you think know the problem best, but ironically, they might have lost awareness to what the novice knows and doesn't know. And so ironically, they're actually not that effective in distilling like the essence of their expertise. Uh yeah, so it's something I'm totally like hope I don't become one of those, you know, paradoxes.

SPEAKER_00 42:08

Or maybe it's a lesson to the learners among us that there's many ways to gain knowledge besides asking someone to tell you what they're thinking. And I can't emphasize enough. I know I keep saying in the role modeling and the observation, but you know, when I think about parts of how I do my exam, it's because I saw, you know, the way you do your reflex exam or the way some of my other mentors did their, you know, dorsiflexion testing and how strong I really need to push down. So it's this idea that you don't let the opportunities to learn escape you by as well as a learner. It's a kind of a two-way street, as you said.

SPEAKER_01 42:42

Yeah, that's well said. I totally still agree. Like it's I don't think, I mean, maybe in some maybe not too distant future where we can just, you know, beam all this knowledge into your brainstem, like the matrix, that we don't really need the apprentice experience. But I I don't know. I don't think so. Um that I mean we might be farther away from that. Um I like so I just still think you need these, you need these people. You know, like you're definitely better off with a core set of people who can actually transmit this knowledge intergenerationally. And it's a the chain is weakest if there's one gap in it. And then you know, you don't then like the next generation really doesn't have that reference. Um and then they're either rediscovering things or that it's just maybe lost. That the the effectiveness of what they once knew is just not really maintained because it's hard to read these things. I mean, I like I read a lot, I thought, going into I thought I thought I was prepared, and then it wasn't didn't take long before you're sort of beaten with the reality that, like, no, I actually don't know anything of what I'm doing at the bedside to figure this out. Like, I don't, I need help. And uh like preparedness only went so far. Like I was stalking lists and reading about patients, like I was a bit obsessed, you know. But I like I built up my probably my training model to like neurological problems, but like bedside effectiveness of like acquiring that information, both like how you get the history and Do the exam, I was bad at it. And like I it took it was I had to recognize realized that. But I only got better, I think, through like a couple of key people, um, both who are good at distilling it, but then also inspiring you to get better at it. And that that's still to me like the the secret sauce of the whole thing. Like it's worth uh valuing that. I hope it's valued, to be honest. You know, I I sometimes have my doubts about this, but that there's something there, you know, that it's like if you know, you know, but like it can be easily, I don't know, been like, okay, well, yeah, at the end of the day, we're just gonna get the MRI here, right? And then you just sort of get a little bit cynical about maybe this is this process stuff is, you know, maybe not as I still think it's important, but I just hope that it isn't like it's it seems potentially dismissible.

SPEAKER_00 44:51

Yeah, it seems more obvious in other scenarios. Like you said, you're basically describing like you read every single textbook in the library on tennis, and then they handed you the racket and you didn't quite know what to do. And so I think we we sometimes fail to realize that medicine is quite similar. There's a art to it, there's a science, there's a practice to it, uh, there's a motor of practice, especially within neurology. And I just love what you said about the opportunity to recognize the moments around us and their value. And I hope people listening um realize that the work they do as role models or what they do as teachers is valued. And I hope that, as you said, we can maintain an understanding and a and an actual consciousness explicit knowledge of the role of that apprenticeship and its importance in developing the next generation of neurologists.

SPEAKER_01 45:42

Yeah, I live with the hope that this is still, I mean, my research is in these rare neurologic diseases, and I am still of the believer that while a lot of these diagnoses we can sort of infer or even make outright with their genomes only without even seeing the patient, when you find something new, you have to have the capability to have very good bedside um technique to both capture the phenotype and all of its complexity to be able to pair it with like what you find in the lab or you know in their in their genetics. So I I think this is still a core skill and worth attention and difficult to do. I think it's like an enormously challenging thing of how we um can transmit this skill um, you know, down the line. It's not that old, right? It was like uh, you know, the neurological method or whatever. It's like we're like a hundred years into the formal exam. I mean, I don't like that's not that long. We're like two steps away from three generations away from people not knowing anything on what you know what to do with the exam. It's like so we're like, you know, do it it's not that many people who have transmitted this so far. So you hope it can sustain.

SPEAKER_00 46:54

Well, VJ, this has been such a wonderful conversation from walking the walk to talking the talk and emphasizing that until um you know people can uh beam knowledge or maybe AI into our brainstem, we still need our bedside educators and uh the mission uh educators. So thank you so much for joining me today. Is there anything else uh you'd like to add? Any final thoughts?

SPEAKER_01 47:18

No, Colina, it's been so nice. I mean, again, I just to reiterate the point, just seeing someone like you at now multiple stages and now as like a colleague, it it it just again, it's something that renews the hope and the whole endeavor. You know, there's many things that can be a bit depressing uh in academic medicine. Um, but your in continued enthusiasm from like you know, you you can see it in other people's eyes. And I take you as one of those examples, and just now, like, you know, delivering that and and expanding upon it and sharing this is uh it's an honor to be a small part of it.

SPEAKER_00 47:52

Oh, absolutely, my pleasure. I mean, as I said, like you know, you we have these moments. Um we you know bump each other into each other in the hallway and say hello and conversation like this, and knowing that others are out there, it may be a lonely sport at the time, but you're part of a big community that's all um gearing for the same thing. So thanks, Vijay. Thanks for being such an inspiration and a wonderful colleague and friend and educator. Neuropraxis, the Neurology Educators Podcast, was created and produced by Galena Gayman. It is not recorded as an official podcast of any institution or organization. The views and opinions are those of the individual speakers themselves. Music from Pixabay. Cover art by Carolyn Bolney, editing by Valeria Rowlden. Want more content like this? Be sure to subscribe to the Neuropraxis Podcast wherever you get your podcasts. Have questions, comments, or suggestions for other podcast episodes? Contact us at neuropraxispodcast at gmail.com. Tell your friends and spread the word. Thanks for joining us.