The Neurologist Is In, Episode 11, Part 2: How to Pursue an Educator Role, With Dr Mark J. Milstein

In this episode Rachel Marie E. Salas, MD, MEd, continues her conversation with Mark J. Milstein, MD, FAAN, to discuss how he discovered his interest in medical education, what those interested in a similar role can do to pursue it, and future trends in neurology training.

Listen to Part 1: The Role of a Neurohospitalist here! Part 3 coming soon.

Can't get enough of The Neurologist Is In? Make sure you're caught up on all the episodes--find the full catalogue here.

Rachel Marie E. Salas, MD, Med, FAAN, FANA, is a professor in the Department of Neurology at Johns Hopkins Medicine with a joint appointment in the School of Nursing. She is board certified in Sleep Medicine and Neurology. Dr Salas is the Director of Ambulatory Sleep Services at the Johns Hopkins Center for Sleep and Wellness. Dr Salas has been the Director of the Neurology Clerkship for over a decade. She is the Chair of the Undergraduate Education Subcommittee for the American Academy of Neurology and is an appointed member of the Alliance for Clinical Education. She is the director of the Interprofessional Education and Collaborative Practice for the School of Medicine and a Co-Director for Interprofessional Teaming for the High Value Practice Academic Alliance. Dr Salas is also the founder and Co-Director of the Johns Hopkins Osler Apprenticeship Program (in Neurology), a medical education research program for senior medical students and the Johns Hopkins PreDoc Program, a pipeline premedical college program. Dr Salas is a certified strengths coach and uses a strength-based approach and coaching to connect to, support, and develop those involved with her educational mission and clinical practice. Dr Salas is a 2019-21 Josiah Macy Scholar, a 2019-20 AMA Health Systems Science Scholar and a 2021 AΩA Leadership Fellow.

Mark J. Milstein, MD, FAAN, is Director of the Adult Neurology Residency Training Program at Montefiore and Associate Professor of Neurology and Medicine at Albert Einstein College of Medicine. His clinical work focuses primarily on neurohospitalist and neuromuscular medicine / electromyography (EMG), as well as general neurology.

After earning a degree in Biology at the University of Pennsylvania in 1997, Dr. Milstein attended Albert Einstein College of Medicine, where he received his Doctor of Medicine in 2001. Dr. Milstein completed five years of postgraduate training at Montefiore from 2001-2006, including his internship in medicine, residency in neurology and fellowship in clinical neurophysiology. Dr. Milstein was Chief Resident in the final year of his neurology training.

Dr. Milstein’s research focuses on medical education, inpatient neurology and neuromuscular medicine. His work has been published in a number of peer-reviewed journals, and includes original research, review articles, and books. Dr. Milstein has been an invited speaker at a number of national lectures and presentations.

At the 15th Annual Doctors Recognition Day in 2018, Dr. Milstein received the Peer to Peer Excellence in Medicine Award from the Bronx County Medical Society. He is a member of numerous professional societies, including the American Medical Association (AMA), the American Academy of Neurology (AAN) and the New York State Neurological Society. He holds leadership positions in the AAN and the New York County Medical Society (NYCMS).

Read the Transcript:

Dr Rachel Salas: Welcome back everyone to The Neurologist Is In. I am Dr. Rachel Salas, a sleep neurologist at Johns Hopkins. And I have the pleasure of speaking with Dr. Mark Milstein today. Mark, go ahead and introduce yourself.

Dr Mark Milstein: Thanks so much, Rachel. My name is Mark Milstein. I am an associate professor of neurology and medicine at Montefiore Medical Center in the Bronx, New York. We're affiliated with Albert Einstein College of Medicine. I split my time between clinical work as a neurohospitalist and as a neuromuscular neurologist. And the other hat that I wear is as program director of our adult neurology residency program.

Dr Salas: We couldn't have this interview without you speaking on your hat as an educator and as a teacher. So walk me through that. How did you become a program director? Is that something that was on your radar when you were in training as a medical student, or did you just kind of like fall into it?

Dr Milstein: So probably somewhere in between, I think. If you had asked me when I was a medical student, I don't know that I would've said I'm definitely going to have teaching as a component of my future career. I'm continually impressed by the candidates that come and interview at our program, who are thinking about a future in neurology, because I feel like they've thought through some of these things far better than I did when I was a medical student.

But I told you I grew up in a medical house. I also grew up in an education house. So my father is a physician and for a good period of time, was program director of his residency training program and also wore some education hats at the medical school as well. And my mother, for her entire working career, was a teacher. So that was a built-in maybe genetically and environmentally from the start. I realized when I got to residency that I enjoyed explaining neurology to other people, not just to patients, but to peers, to junior colleagues. I really liked helping people understand that neurology isn't as complicated as people think it is. And so I think during residency training, what that helped me realize is, well, you should stay in an academic setting. I don't know, even in residency, that I knew for sure until I was getting towards the end of residency. I was fortunate enough to be chief resident during my neurology residency training and that really started to build my educator values and skill set.

And again, and you'll probably hear me say this three more times during this podcast, I had fantastic mentorship. There were people here at the program who recognized that I likely had a skill set that could be developed. And so as I started as an attending, immediately I was doing teaching because my primary clinical role was, and I was doing much more inpatient service back then when I wasn't the program director, was teaching the residents on the inpatient consult service. You have to be excited about the job that you were hired for and the work that you're going to do, because it's going to affect everything that you do at work. And I recognized that teaching was something that was exciting for me. The program director who preceded me, recognized that. And we had some career conversations, and initially I became a education director for one of our training hospitals, and then rose into the associate program director position. And after that, was lucky enough to transition into the program director spot when my predecessor was ready to step down in 2013.

I will tell you that my two hats, my educator hat and my clinical hat, they serve each other. When the administrative responsibilities of being a program director feel like they've gotten a little bit too stressful for me, suddenly a clinical block comes up. And when the clinical block has been a little more tiring than I expected it to, I realized that I have a lecture to prepare for, or I have another exciting opportunity that's related to my program director job. So I really enjoy the balance that being a program director gives me, but also that possibility of being an educator every day, is something that's exciting for me. It has been a great fit.

Dr Salas: Yeah, that's so great to hear. I can not only hear, but feel the passion that you have. If somebody was listening to this and was thinking, "You know what, I never thought about being a program director." What would be some recommendations you would have now, knowing that in the last, I don't know, 5 to 10 years, I think before teacher and educator were kind of one and the same, but now people are getting formal training, now they're getting leadership opportunities. So what would you recommend if one of your residents, for example said, "You know what, I think I might like to be a program director." What recommendations would you have?

Dr Milstein: So after I finished being excited and gushing for 15 or 20 minutes because one of my residents wanted to rise towards that goal, I think there's fortunately, there's again, a lot of different pathways that you can take. And I don't think you even necessarily have to be, for your whole career, in an academic environment to move towards that goal. Obviously, if you want to be a program director, you're going to have to transition to an academic health system, but even people who might be listening to this who are in private practice right now, if they're looking for a change, I think there are some opportunities.

Thinking from the resident perspective, it's about finding early opportunities to be a teacher. I think there are skills, absolutely, that can be trained and coached and mentored, but nothing beats the hard experience. So I look for opportunities to get them involved with the medical students early on, and not just the standard things that residents do, such as helping medical students when they're on their clinical clerkship, but even in their foundational courses. We've integrated our residents into the physical exam teaching course at the medical school. Our senior and chief residents, have been involved in some of the small group sessions that the medical students do during their neuroscience course during the clinical portion of their neuroscience course. And we pair them up with one of our educators so they can get some mentorship while they're doing that. I believe in developing independence, but I don't think anybody should fly without a net from the early stages. So that's a very early thing that we can do.

We've tried to build lectures into our standard didactic curriculum. We call them "Teach the Teacher" lectures, so that people can recognize good behaviors and bad behaviors in themselves and in other people, and how to address those. Teaching people how to meet a mixed audience where they are. So our residents all present in a weekly case conference where they're expected to take an audience that ranges from third year medical students to 30, 35 year experienced attendings, take them through a clinical case and everybody expects to leave at the end of the session, having learned something. That's a real skill set, being able to teach to that diverse an audience. So those are all the things that you can even do during residency.

Post residency, it doesn't matter what you choose from a clinical pathway. If you're choosing an outpatient fellowship or more inpatient minded fellowship or end up doing a mix like I do. It's about looking for the opportunities. It's about making sure that the people who work with you, that the people who supervise you, know what your interests are. Saying early, "This is something that I like doing. This is something that I'd like to do more," is music to the ears of a leadership team in a clinical department. And so that's what happened for me. I was given teaching opportunities. I was allowed to take on a small education leadership role at one of our hospitals. I worked as a preceptor for the clerkship and started to build that skill set. If you aren't in a working environment that perhaps is as developed as that, then you can look for other possibilities. So if you are affiliated with a medical school, the medical school frequently will do faculty development training courses, and I would encourage people to look out for those. Certainly here in New York, Albert Einstein College of Medicine, has a very robust faculty development curriculum and I've definitely learned a lot of things, particularly about giving feedback and other skill sets that an educator certainly needs.

Beyond that, then it's looking less local and maybe looking at the larger organizations, using something like the American Academy of Neurology, for instance. There's faculty development and curricular development courses that are given at most of the meetings of the American Academy of Neurology. You might find something in your state neurologic society as well. Many state neurologic societies have annual meetings and have curricular development there. So it's a little bit about pinpointing the opportunities, it's a little bit about making sure people know that it's something you want to do. And then, again, about finding the mentorship to help you develop to the best educator that you can be.

Dr Salas: Yeah, no, I think that's great. And I think the other thing that it's important for people, especially house staff and medical students, that may be interested in having an educator leadership role in the future, is that these positions do come with some salary support. I often say not enough, especially for program directors, I mean, it's kind of 24/7. You're always tied to the residents for sure. But there is salary support. And I think that's nice because as physicians, like you've mentioned earlier, we all teach. We all teach even our patients. And as we are neurologists, whether you're an academic or private practice, you might be a preceptor and those aren't always paid, it's part of our citizenship, right. But there are these positions, like the program and fellowship directors and the clerkship directors that you do get some support.

Dr Milstein: I think that is an important point to make. And of course, I know you're not saying this, it's not from the greed and earning point, as you said. You're really just replacing one job with another job. So it's work that you're doing that you should be paid for. But I think it was an important piece for me. I started with predominantly a 95% clinical job. And in fact, the job that I was hired into when I started as an attending, I don't think anybody would take in 2022. We've learned some lessons from that. And I joke with the leadership team in the department, some people who are still in the same positions that they were in when I started as an attending, I joked that they were all kind of talking to each other behind the curtain saying, "Hmm, I wonder how long Mark can tolerate doing this job because he seems to be liking it so let's just let him keep doing it." And I was lucky that I had people that I could confide in, people that I could talk to about that I was looking to develop. Around 2 or 3 years into doing the job, it occurred to me that I wasn't doing a lot of other projects at work. I didn't have any real research opportunities, thinking about working on manuscripts or other projects that somebody might do. And I looked around and I said, "When do my colleagues do this?" And they said, "Oh, they do this when they're not on service." And I was on service all the time. And so I think we've even learned those lessons inside the department when we've hired new people on. Nobody comes on for a 48 week year job, plus the four weeks of vacation. Nobody does, 48 weeks of service anymore. And it's to give them that space, to have those other projects ,and take care of those other interests. So that's been important. And I use the word balance before. It's been a very nice balance for me between the clinical and the administrative and the educator jobs. You have to be well at work, right? And so finding where your balance needs to be is important.

Dr Salas: Yeah. No, I think that's really great that you say that. So looking ahead, now that you obviously went through training and now have been in this role as program director for several years. And we're going to talk about your leadership roles in a second, but what do you predict for the future in the next 5 to 10 years in terms of neurology training? What is that looking like? What are some of the challenges that we have to think about now so that we better prepare our trainees for the future? I don't know if it's a prediction or what would you hope for, but tell us a little bit about what your thoughts are in the next 5 to 10 years in terms of residency training in neurology.

Dr Milstein: I guess I am just as curious as you are, as to what the next decade looks like in residency training, and I don't think this is specific to neurology. I think this is a little bit across the board in graduate medical education. There's been a Renaissance, maybe over the last decade, but particularly over the last 5 years of saying, "If we're going to call our residents students, then we have to treat them like they are students." And they are students who are employees, but they are people who expect to learn and expect to grow. And they can't always be the answer to the question, "Who's going to take care of this?" Right? Health systems have grown exponentially over the last decade, expanding both within their own footprints and taking over smaller hospitals and creating larger networks that create huge referral bases of sick patients that all end up in the hospital where the residents are. And the residents are just expected to take care of those patients. And, I don't say this in a bad way, the era where we say, "While you are a resident, we own you. And it's going to be a hard 3 years or 4 years or 5 years or 7 years, depending on what you're doing. Then it's going to be over and you're going to reap the rewards." Because that's not how the world works. And I really do believe that while anybody would say that they had a hard time during residency, what was a hard residency for you and I, I truly believe is different than the hard that our residents are experiencing right now. I think we have continually piled more and more and more on the residents, and we need to stop them from reaching their breaking point. It doesn't matter what we give the residents, if at the end of those 3 to 7 years, they don't like being a doctor anymore.

So I have been very engaged in the wellness Renaissance. I still use the nasty B word, burnout, right? I don't think wellness is the opposite of burnout. I think those are both topics that we need to discuss. I also think that we haven't found the balance yet, which is a common concern when you're trying to solve a problem. You swing too far in the other direction. What I want to see in the next five or 10 years, is showing the residents how you can create a work/life balance that will work post-residency, right? Just like I said, you can't tell a resident that they have to do everything. If you tell a resident that they don't have to do anything, then they are going to be in for a very rude awakening when they start their clinical practice, whether it is in an academic center or particularly if it's in a private practice, where the economy is going to drive your work product a little bit too. And so we have to help residents find their own pathway that makes them happy and satisfied, as opposed to saying, this is too hard work and this is too easy work. It's about finding the right work. And that's where I think residency training is going to go over the next five or 10 years. And I don't think that's neurology specific, but I think neurology training has taken a particular hit, because many of the amazing developments that have come to neurology in the last 5 to 10 years, are developments that require much more aggressive, much more acute care. And many people in our generation and many people in the generation above us will say, "One of the reasons I went into neurology is so that I could talk about things for two and a half hours before I did anything." And that's just not modern neurology, right?

I do think, and I am hopeful, that integrating education into all residency training programs is going to be the future of graduate medical education. I think "doctor as educator" is an important pillar of residency training, and people will do it at different levels, of course. Not everybody is going to be a lecturer at a medical school. Not everybody is going to be a program director or a preceptor. But as you said earlier, we all have a responsibility to our patients. And that is a skill set that needs to be developed in every physician.

Dr Salas: That was a wonderful wrap up. And I think I agree with you. I think the personalization about really meeting people where they are, meeting the residents and helping guide them to develop whatever kind of practice and whatever kind of neurologist they want to be, is kind of where we're going. I couldn't agree with you more.