AMBOSS: Beyond the Textbook
AMBOSS: Beyond the Textbook
Part 1 of 2: A Global Perspective on Shaping the Future of Neurology and Medical Education with University of Rochester Professor Dr. Ralph Józefowicz
Welcome to Season 2! In this episode, Dr. Tanner Schrank interviews Dr. Ralph Józefowicz, a professor of neurology and medicine at the University of Rochester in New York. Dr. J. shares his insights on neurology and offers tips for medical students pursuing a career in this fascinating field. This interview is part 1 of 2.
Listeners can gain valuable knowledge and advice from Dr. J., who has extensive experience in neurology and medical education. He discusses the unique challenges and rewards of being a neurologist, the importance of integrating basic sciences with clinical applications, and the differences between medical education systems in the US and Europe.
Read More:
Dr. Józefowicz: https://www.urmc.rochester.edu/people/21276224-ralph-jozefowicz
Neurophobia: The Fear of Neurology Among Medical Students: https://doi.org/10.1001/archneur.1994.00540160018003
AMBOSS: Succeed on Your Neurology Rotation: https://www.amboss.com/us/shelf/study-for-neurology
AMBOSS: How to Prepare for the Transition to Residency: https://blog.amboss.com/us/how-to-prepare-for-the-transition-to-residency
Book rec: "Mastery" by Robert Greene: https://www.amazon.com/Mastery-Robert-Greene/dp/014312417X
Fun fact: https://bigthink.com/neuropsych/what-age-is-brain-fully-developed/
Sign up for a free 5-day trial at https://go.amboss.com/pod-5day-trial.
Read more at the AMBOSS blog: https://go.amboss.com/blog-ambosspod.
Find out more about the AMBOSS podcast: https://go.amboss.com/int_podcast-23.
Hello and welcome to season two of the Ambos Podcast, beyond the textbook where we provide medical students and physicians with in-depth insights and expert knowledge that goes beyond traditional medical textbooks. I'm your host, Dr. Tanner Shrank, and today we have a very special guest joining us, Dr. Ralph Uvi, known as Dr. Jay by his students. He is a professor of neurology and medicine at the University of Rochester. in Rochester, New York, served as the Neurology Residency Program director. And he was also my neurology professor at Yon University Medical College here in Kaku, Poland. Today, he'll share his insights on neurology and tips for medical students pursuing a career in that fascinating field. This interview is part 1 of 2. So before we dive in, I'd like to remind our listeners that the Ambos platform offers an extensive library of neurology resources, including comprehensive articles, multimedia content, and an interactive question bank. So be sure to check out the ambos app for on the go, access to these resources and visit the link in the show notes to learn more. For Season 2, we're adding a few new segments. Before our interview begins, I'll give our listeners a question from the Ambos question Bank We'll give you the scenario and the Question at the top of the show and listen until the end to find out the answer. Here's your question. In clinical neurology, a 31 year old woman gravita one Parra zero at 28 weeks gestation comes to the obstetrician for a prenatal visit. She has had a tingling pain in the thumb index finger and middle finger of her right hand for the past six weeks. Physical examination shows decreased sensation to pinprick, touch on the thumb, index finger, middle finger, and lateral half of the ring finger of the right hand. The pain is reproduced when the dorsal side of each hand is pressed against each other. Which of the following additional findings is most likely in this patient? A Palmer nodule BNA Atrophy. C Interosseous wasting D wrist drop or e hypoth, our weakness Alright, Dr. J thank you so much for joining us today.
Dr J:It's my pleasure.
Tanner:So, to start with, could you please share with our listeners a bit about your background and what led you to pursue a career in neurology?
Dr J:I was born in New York in Brooklyn, and I'm 30 generation Polish American, and I went to uh, Jesuit High School in New York City, Xavier High School. Then I went to Johns Hopkins University where I got my undergraduate degree and Columbia University in New York City where I received my medical degree. Following that, I went to the University of Rochester for an internship in residency in internal medicine for three years, followed by three years of a neurology residency and a two-year fellowship in neuromuscular medicine. I started out in internal medicine because although I was interested in neurology back 40 years ago, The typical route getting into neurology was to do some internal medicine first. And so I did three years and then I did neurology. And one of the reasons I selected neurology was, first of all, my older brother was a neurologist, and I think that had an influence on me. But secondly, I really loved the elegance of the nervous system and the brain, and the fact that this controlled us as humans, not only our motor and sensory activities, but also our thoughts, our language. Vision. All of these things that make us human. It's also a very elegant system from the standpoint of the anatomy and the physiology and the pharmacology, and what I really like about it is the approach to evaluating patients with neurologic disease is not about tests. It's about taking a history. It's about listening to the patient and performing a neurologic examination, which is very elegant and which is about 95% accurate in localizing the lesion. We get imaging studies to basically confirm our suspicions, but a good neurologist basically knows what's going on at the end of the history and the physical exam. So I feel it's a specialty where my skills as a physician are Exactly why I went into medicine, to take a good history and to do a physical examination on a patient. Plus the diseases that we see are numerous and interesting. Neurology. It takes care of adults and children, men and women, inpatient and outpatient. And I follow many patients for years because of their disorders, their migraine headaches, their seizure disorder some cognitive issues neuropathy, for example. So you really develop. a close relationship with your patients. Now, my career, I also got very interested in education. As a medical student. I loved teaching junior students when I was a fourth year student. then in residency I loved teaching medical students. And this was recognized by one of our faculty members who taught the neuroscience course. after I finished my fellowship, I was asked to become the co-director of the neuroscience course, and then I be. Became the director of that course. I became the neurology clerkship director and then the residency program director. And I ran all three of those for 25 years until I stepped down a couple of years ago, not because I was disinterested, but I'll be 70 years old this summer. And as my mother always said, you have to make room for the young people. But it was a very fulfilling career. I became very active nationally with the National Board of Medical Examiners, and I really had an impact on mentoring individuals interested in education and the way my international programs developed. Started with the Sister City connection between Kakou, Poland and Rochester, New York. And in 1992 I had my first Fulbright and I spent five months in Kakou teaching neurology and English at Yon University. Then several years later, the medical school here started their English language program and the chair of neurology invited me to come and teach the neurology clerkship. Well, this evolved over 25 years where I've been going every single year for a month, bringing my chief residents, bringing medical students from Rochester bringing faculty over from Rochester, and also a parallel exchange program where we. Brought hundreds of students from Yon University, from both the English and the Polish language programs to Rochester for clinical rotations. Plus we've had a dozen faculty development workshops in both countries. I also started a program with the University of Navarra and Pamona Spain, and for six years I've been going there for two weeks to teach a neuroscience elective. And essentially I've just had an absolutely terrific career. Presently I'm still teaching, although I'm not running programs, I'm seeing patients, inpatients and outpatients. I travel to Poland for a month every year. I travel to Spain for two weeks, and I don't see myself retiring anytime soon because I absolutely love what I do.
Tanner:That's great. Yeah. And it touches on so many important points. I think about a well-rounded physician, not just taking tests and not just ordering diagnostics, but actually talking with people because that's what we're trained to do, is help people not just find the solution. So, Neurology is a really interesting choice. It's often considered one of the more challenging fields in medicine. you even wrote a paper about it back in 1994 about the difficulties medical students have with neurology called neuro phobia, the fear of neurology among medical students. So what do you think are some of the unique challenges and rewards that come from being a neurologist?
Dr J:Well, the neuro article was very interesting. I wrote that uh, as you said in 1994. And it was based on a talk I gave at the American Academy of Neurology. It's the fear of neurology that medical students have because it is typically taught poorly. Neurology is complicated. It's not just one organ, like a kidney or a heart. It's basically a very complicated system. And the problem with the way it's taught is in the basic science years of medical school, it's taught by basic scientists who really do not know the clinical application of what they're teaching. And then when the students. Rotate on the neurology clerkship in their clinical years. They don't recall any of the basic science and they don't understand how the neurologist could basically listen to a patient and examine them and come up with a diagnosis. So the point of the article was that neuro is a very common disease among medical students, and it's mainly due to the lack of integration of the basic sciences in the clinical application and in Rochester. We have been integrating this right from the get-go. In fact, our neuroscience course, which is now the Mind Brain Behavior course, is taught primarily by clinicians. And I teach all the neuroanatomy, even though I'm not a basic scientist, I don't have a PhD. I'm just a clinician, but I know the neuroanatomy and when I teach it, I always use clinical examples to make it interesting. And even just recently, I finished teaching a four week course here at Gian for the medical students in the fourth year in their English language program. They really mentioned that it was the best course in the curriculum simply because it was extremely well organized and it really had a clinical focus and it employed the use of case studies to basically teach the various disease processes.
Tanner:Yeah, that's so true. That's what I remember about my course. It was so much more memorable than just a PowerPoint because it's the actual cases, it's seeing patients in the wards and having to start from the beginning and write a patient note and take care of the patient. So yeah, I think that's really good. And you mentioned neuroanatomy you're listed as an author on Netters Atlas of Human Neuroscience,
Dr J:well, yeah, I co-authored that with David Felton. David was an MD PhD physician in Rochester who actually ran the neuroscience course and he and I co-directed the course for many years and we became really good friends.
Tanner:that's great. So you really know your stuff, you know, all the ins and outs of neurology. You mentioned your experiences in the US, in Rochester, New York, and here in Poland. So had this unique opportunity to both healthcare systems, both medical education systems. Could you share your thoughts on the similarities and differences between the two systems, and maybe are there any lessons to be learned there?
Dr J:Sure. So from the clinical standpoint, I have to say that the level of medical and neurologic care in Poland has essentially ascended to parody with the US system over the past 20 years. I came here, 30 years or so ago? There clearly were differences in the way neurology was practiced, and especially with the treatment. But now YA University opened up a brand new hospital 950 beds, and it's a state-of-the-art hospital and they have two neurology wards, 24 beds each. One is the stroke ward, one is the general neurology ward, and I spent um, five months here last year on my second Fulbright, And I have to say that the way neurology practiced here in Kaku is exactly the same way that we've practiced it in Rochester, New York. All the medications, all the new treatments. I V I G, plasma exchange, dupa therapy deep brain stimulation in Parkinson's disease. All of that occurs here just the way it does in Rochester and the level of knowledge of the physicians is equal to that of our physicians in Rochester. From the standpoint of education, it's really the difference between the European system and the American and Canadian system. I think everyone knows the American and Canadian system includes four years of college and then four years of medical school and medical school. Basically in both US and Canada is really focused on teaching clinical skills, especially in the third and the fourth year with the students who are attached to teams. They have responsibility for patient care. They write notes. They write orders. Obviously they have to be countersigned, but. The bottom line is when they finish medical school, they're ready to basically assume patient care. In Europe, the system is different. It's a six year program after high school, so the students are a little bit younger. And secondly, it really focuses more on teaching. Knowledge. In fact grades are typically based on examinations as opposed to clinical performance and the level of knowledge of the students here at YIAN equals that of the best schools of the United States. But The clinical rotations include having four or five students on a team see one patient with a professor, and they discuss what's going on. They examine the patient, but they don't participate in day-to-day patient management. So when they graduate in Poland there's a one year stash, which is like an internship. But that's where they basically learn their clinical skills. Whereas us medical students, when they start their residencies, they're already knowledgeable about how to patients.
Tanner:Yeah. And that perfectly lines up with my experience here. In my last year of med school, I was in the wards. I remember in the ICU I was helping place lines, and we did some work with some fresh doctors, right? Some interns. And they didn't know how to do it, but I did because we were preparing for these clinical skills that we need to know for the US and they were learning for the first time.
Dr J:the other difference in Poland at least, is the hours in medical school are less than in the us but if students have an interest in a specialty, they join one of these scientific circles, and there they spend evenings, nights, and weekends. Extra time out of the curriculum in a specialty, working with physicians. And if they're good and they're interested, the physicians will teach'em more and more. Mm-hmm. So basically a student has to take initiative here to basically learn along those lines. Whereas in the us assume in Canada also, it's really all part of the curriculum.
Tanner:Yeah. Let's continue that line of thinking. For medical students who are considering a career in neurology, what advice would you give them to help them succeed in the field?
Dr J:Well, I think it's true for any specialty in order to be successful you know, you need to be smart, good, and nice. These are the three things that we look forward when we select residents for our program. So you really have to work hard and learn the material. so that's the first thing. The good part is you need to have good clinical skills. So you have to basically learn how to take histories, examine patients, and really think in a very logical fashion. I occasionally have some residents who have problems putting it all together. They eventually do after their residency, but it's not intuitive for them. They collect information, but they don't know how to put it together. Mm-hmm. Whereas, you know, the skillful physician basically. When he or she hears the chief complaint already starts thinking of the differential and the history basically narrows it down. So it's basically doing very linear processing that by the time you're finished with the history, pretty much you have your diagnosis and then your focused neurologic examination will confirm the diagnosis. And then if we get an imaging study that basically will. Confirm the diagnosis further or maybe bring up some other aspects in the differential. So I think to be successful, you have to study real hard and you have to take initiative and you basically have to know why are you doing this and what do you want to do?
Tanner:Yeah, that's so true. Dr. J, Thank you so much for sharing your insights and expertise with us today. It's been a pleasure speaking with you, and I'm sure our listeners have gained valuable knowledge from this conversation. And we'll hear the conclusion to this interview in part 2, coming in 2 weeks.
Dr J:Thanks, Tanner. It's a pleasure.
Tanner:and to come back to that question from the top of the show, let's see what that 31 year old woman had The key info was tingling pain in the thumb index finger and middle finger of her right hand. The decreased sensation on the lateral half of the ring finger and. The pain was reproduced when the dorsal sides of each hand were pressed against each other. The attending tip says, A positive Phin test, pain, or tingling with passive flexion of the wrists suggests median nerve impingement in the carpal tunnel. With all of this information, you should have selected. B Thena atrophy because carpal tunnel syndrome is the most common upper extremity neuropathy and is especially prevalent in pregnant people due to hormone associated weight gain and Peripheral edema compressing the median nerve, the theen muscles are integrated by the recurrent branch of the median nerve. Compression of this nerve in the carpal tunnel can therefore cause thena atrophy. Branches of the nerve also provide sensory innovation to the Palmer aspect of the thumb index finger, middle finger, and lateral half of the ring finger, which is why she had pain and paraesthesia in this distribution. You can read up even more about carpal tunnel syndrome and this question on the ambos platform and in our question bank, and here's your fun fact of the episode. not only does the brain finish developing around a person's mid to late twenties, but the brain begins developing at the back and moves towards the frontal lobes? Specifically the prefrontal cortex behind your forehead is the last part to mature. and this area is responsible for planning, judgment and making good decisions, and we'd like to start recommending. Books for students to read that are not textbooks. So your first recommendation is the 2012 book by Robert Green, entitled Mastery. This book talks about gaining mastery over a field, If you have any other book recommendations that you'd like other listeners of the podcast to know about, please email them to us, and maybe we'll read it out on a next episode And that's a wrap for today's episode of the Ambos Podcast beyond the textbook. Thank you all for tuning in, and we hope you enjoyed this conversation. Be sure to subscribe to our podcast for more insightful episodes, covering a wide range of topics in the medical field. If you haven't already, don't forget to check out the Ambos platform and download our app for comprehensive neurology resources and much more. Until next time, I'm Dr. Tanner Shrank, and this has been Ambos Beyond the textbook.