NeuroVoices: Fabio Nascimento, MD, on Improving EEG Education in Residency Programs


The clinical fellow at Massachusetts General Hospital detailed his research on neurology resident EEG education, and the increased need for more consistency throughout programs.

Fabio Nascimento, MD

A recently published paper by Fabio Nascimento, MD, and Jay Gavvala, MD, MSCI, identified a lack of consistency in teaching and evaluating resident electroencephalogram (EEG) education as barriers, while also presenting possible solutions. The 2 researchers distributed an online survey focused on characteristics of neurology residency programs and their EEG teaching systems to adult neurology residency program directors (PDs).

Among the 47 PDs that completed the survey, the average number of EEGs read during a typical EEG rotation varied from ≥40, in about one-third of programs, to 0–10, in about 14% of programs. Additionally, 64% of PDs reported that there was no use of objective measures to assess EEG milestones. Insufficient exposure and ineffective didactics comprised of 32% and 11% of the most commonly reported barriers to EEG education, respectively.

Nascimento, an EEG/epilepsy clinical fellow at Massachusetts General Hospital, used this paper as a way to raise awareness and bring attention to an issue he feels is already well-documented within the residency space. In the latest edition of NeuroVoices, he outlined the most crucial findings from his study, the need for more standardized number of EEG reads, and the consequences a lack of EEG education can have on patient care in a clinical setting.

NeurologyLive: What motivated you to conduct this study? What important value does it hold?

Fabio Nascimento, MD: Jay Gavvala, MD, MSCI, and I wanted to better understand how EEG is has taught adult neurology residents in the US. That’s sort of our research question. From our experience, myself as a recently graduated adult neurology resident 6 months ago, and Dr. Gavvala, who is a seasoned academic EEG’er, we felt as though adult neurology residents do not receive optimal EEG education throughout their training. This has been a widespread known fact among centers and residents. The problem translates into residents graduating without being able to read EEGs independently, which is exactly what the ACGME (Accreditation Council for Graduate Medical Education) expects us to do as far as the neurology milestones. That was our main motivation.

Do you think there should be a standard number of EEG reads during a typical rotation?

That’s the million-dollar question, and honesty, nobody really knows. Nobody knows how many EEGs a neurologist must read to become competent. This has been something that centers in the US and abroad are trying to achieve and find that magic number. It’s an ongoing discussion, but we have to get there. I wish I had a full answer, but hopefully soon.

What are some of the puzzling findings that you observed?

The first point is that more than 80% of program directors that completed the survey reported and believe that their graduating residents do meet level 4 milestone by graduation. That means that PD’s think the vast majority of their residents are able to read EEG independently upon graduation. If you’re looking at literature, that’s not what’s really out there. If you ask residents themselves, that’s not what they’re reporting. The last triannual AAN survey showed that a little bit more than one-third of graduating adult neurology residents felt confident in reading EEGs independently, the other two-thirds did not. That’s a huge discrepancy between what program directors believe, what’s actually happening, and how residents feel. That was really interesting for us to see.

The second point was that more than half, or 63% of centers across the US that completed the survey, don’t use any objective measures to assess EEG competency, which is fascinating. I think we didn’t have a specific number, but it’s an area that needs improvement.

Is there a disconnect between teachers and students? Is it hard to provide constructive criticism to someone who has a lot more experience in the field?

It’s hard for residents to be outspoke and say, ‘hey, I don’t know anything about EEG, please teach me.’ But on the other side it’s hard for the faculty to know if they’re not expressing something that the students should be knowing. At that level of training, we’re all past medical school, and some past PhD’s. It’s an area that it doesn’t matter if you’re a physician, if you’re not trained to look at EEG and interpret that yourself, it doesn’t matter the level or degree that you have, you’re not going to learn.

You have to start from scratch, sit with someone, read a lot, and practice a lot. Here in the states, EEGs can be read in clinical practice by any neurologist, so anybody who has a neurology residency under their belt can read the EEGs without any further necessary training. That’s a bit scary, because we’re seeing a lot of them don’t feel comfortable, and yet they still read EEGs. That affects patient care, which can have negative consequences to health care systems.

Do you feel as though there should be mandatory amount of experience with using EEGs before graduating? Should some get grouped differently based on the amount of experience they have?

I think it’s really simple, and there’s 2 ways to go about this. Again, this is my personal view. People might differ, but the first option is to mandate further EEG training after neurology residency for someone to be able to read in clinical practice setting. Option 2 would be to continue with the current system where any neurologist can read EEG without having further training, but really harp on improving the EEG education in neurology residency. There’s no other option out there. You improve the EEG education and let all the neurologists with EEG continue, or you request for more training. It’s kind of simple, in a way.

What kind of benefit could precision medicine see if there was more consistency in EEG education from the bottom up?

I think in the world of epilepsy, precision medicine is probably linked with various factors, but EEG is definitely 1 of them. I feel like it’s just basic. If someone reads an EEG and overreads it or underreads it, it’s going to be problematic for the patient. We don’t even need to get fancy into the precision medicine. Giving someone the diagnosis of epilepsy, putting them on antiseizure drugs, and then having them carry that diagnosis and stigma for the rest of their lives is a big deal. Then this might affect their ability to drive for periods of time, how they perform at a job, or their cautiousness with certain activities. It’s a major burden, and that’s from the overreacting standpoint. From the underwriting standpoint, not diagnosing someone with epilepsy when they have that disorder is as bad as the other side. There’s drugs, surgeries, and devices that can help them and improve their quality of life tremendously, and not giving these patients those options can lead to bad consequences. Even in basic medicine, we need read EEG appropriately to provide correct patient care.

Looking forward, where does the change come from? Is this an institutional issue? Monetary issue? Lack of educational awareness issue?

It’s a culture that needs to be changed. The first step is what we tried to do with this paper and what other groups have done in the past is make the problem known by the community, which is what we’re doing now. People need to read the paper, watch the video, and understand that there’s a disconnect between what we’re teaching residents, and what residents are actually learning. Awareness is the first step. We’re getting close to being there, if we’re not there already. That’s exciting.

The next steps will be related to making a meaningful change. That will be more focused on EEG education on a national, and even international level per say. There are other groups out there that have published similar data to us as far as what residents can do in terms of reading EEGs independently. How do we make this change? Well groups have come together and gained an understanding that there need to be newer ways of teaching, and that we need to take advantage of the technology. There are online courses, assessments, and virtual videos that can all be used. New methods of teaching need to be put out there and utilized. Then we need to see if they work or not. We need to validate these methods by conducting more studies to make sure they’re actually doing their job.

The last aspect comes from the fact that we saw no objective measures being used by researchers. We need to standardize our system. How can you compare what 1 resident who is reading 50 EEGs to another resident in a different state who is reading just 5? We need to have guidelines put together by the societies and researchers so that we can establish minimum requirements and realistic expectations. Then of course, you can have some creative wiggle room to implement new ways, but at least you have the solid groundwork for what’s needed for your neurology resident before they graduate.

Was there anything specific that you felt you needed more experience with during your residency program?

I’m guilty myself. We published a lot about residents not knowing enough about EEG, but I’m one of them. I didn’t take the tests because I was doing the research myself, but I didn’t read EEG as much as I should have during resident. My bias was that I knew I really loved it and wanted to go into uplifting EEG. Even with that passion, I still didn’t learn enough. Again, especially based on this study, its not just a problem in my residency program, but virtually all of them. Despite my bias in this field, there still needs to be improvement for sure.

Transcript edited for clarity.

Nascimento FA, Gavvala JR. Education research: neurology resident EEG education: a survey of US neurology residency program directors. Neurology. Published online December 11, 2020. doi: 10.1212/WNL.0000000000011354.
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