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Hello and welcome to the Neophilia podcast. I am your host, Nera Doyle, 1/4 year medical student at the Northeast Ohio Medical University. Neuro. Il is a new medical podcast show focused on neurology. In each episode, I along with top medical experts will engage in interdisciplinary conversations to connect neurology with other fields in medicine. If you are a medical student who desires a clearer understanding of clinical neuroscience, a healthcare provider who wants a fuller appreciation of how neurology relates to your practice or just someone who finds the brain. Cool. Then this podcast is for you. With each episode, we hope you develop an appreciation for and perhaps even a love of neurology to kick off the first episode of the Neophilia podcast. We will be discussing the topic of neophobia, its epidemiology, etiology and what neurologists can do to combat it to accomplish this. I have with me three experts in the field of neurology. Doctors, Blake, Be Let Go, Ahmed ETRA and my Kras Doctor Blake Belet go is a vascular neurologist at the Cleveland Clinic. He completed his residency and fellowship fellowship training at the Cleveland Clinic and was the former medical director of their mobile stroke program. In addition to his clinical responsibilities, Doctor Belet serves as an assistant professor at the Cleveland Clinic, Learner College of Medicine of Case Western Reserve University and is the current program director of Adult Neurology residency program for the Cleveland Clinic. Dr Ahmed ETRA, graduated from Aga Khan University of Health Sciences in Pakistan, followed by his neurology residency training and vascular neurology fellowship at the Cleveland Clinic which he completed in 2015. He is currently a staff neurologist with the Cleveland Clinic and serves as the Medical Director of Stroke at Cleveland Clinic, Akron General along with serving as the lead for neurology education. His interests include clinical research on stroke mechanism as well as quality improvement initiatives for stroke. Doctor Michael Henri is a neurologist in Youngstown Ohio. He completed his residency at Wright State University and a Clinical Neurophysiology Fellowship at Vanderbilt University. He has helped developed and been one of the primary narrators for the journal Continuum Read aloud program as well as recording his own medical education themed podcast, the Neurotransmitters Doctors, Valko ETRA and Kris. It is truly an honor to have you here on the neuro podcast. Thank you so much for your time and participation. So, thanks for being here. So I wanted to start by talking about neophobia. So, what exactly is it? Neophobia was first defined in 1994 by Doctor Joseph. In his Jama published article titled Neuropa, The Fear of Neurology among medical students. Doctor Joseph defined neuropa as the fear of the Neurosciences and clinical neurology. That is due to a student's inability to apply their knowledge of basic sciences to clinical situations. Since its first description, the causes and impacts of neophobia have been studied worldwide including the US UK, Ireland, East Asia and the Caribbean. The first major US study to explore the prevalence of neophobia was performed in 2010 by Doctor Zuk and his team at the University of Connecticut School of Medicine. The study consisted of 100 and 52 3rd and fourth year medical students and internal medicine. Residents of eight different specialties knowledge regarding neurology was the lowest and one of the most difficult disciplines to learn. Moreover, participants had the least confidence when assessing diagnosing and treating patients presenting with neurological disease compared to other fields of medicine. Another study performed in Singapore by Doctor CA M et all in 2013 determined the prevalence of neuropa to be 47.5% in medical students and 36.6% in resident doctors respectively. The commonly cited reasons for neuropa are complexity of neuroanatomy, limited exposure to neurological patients and insufficient teaching of neurological material. So as you can see, neophobia is a complex phenomenon experienced by the global medical community in various stages of training. And with this understanding in mind, we can now move forward to discuss how we can combat neophobia. So, Doctor Bolek, the first question I have for you is how can you make neuroanatomy less visiting without oversimplification? Newer? Thanks for having me and uh glad to be here with uh some of my colleagues. So we're all very excited about your undertaking of, of this podcast. And I think just to start off with um having students like you to, to hopefully stomp out neuropa and really uh have a love for, for neurology is, is really enlightening and it makes us all more excited about what we do. So thank you for doing all of this. Um with regards to your question, um I think that if I had the answer, uh then I, I think everyone would love neurology and, and everything uh would be much easier on all of us and neuropa maybe wouldn't exist. So whenever we talk about neuroanatomy, um it's, it's very complex. I think that part of what we need to do is we need to potentially pause and take a moment to appreciate the complexity of neuro. I mean, I think that if you approach it in the sense of uh thinking that it's going to be something that's easy or something that's not complex or something that won't make you think or spend some time on. Um Then you're gonna set yourself up for, for very little success in trying to understand it. So whenever you're trying to think through neuroanatomy and trying to not oversimplify it, I also think that it takes an understanding of your learner. Um There are a lot of different types of learners and there are a lot of different levels of learning that happen. So we've talked a little bit about neophobia and how it was described in medical students first and foremost. But I think that this is true, not just in trainees uh or students, but I think it's true with staff physicians. I think it's true with other medical professionals. And so I think it's taking an understanding of what level of learner are you dealing with and how does that person learn best. So, you know, fortunately, uh neuroanatomy doesn't change all that much. Uh day in and day out. Certainly there are a lot of complex variants which you can really get into some intricacies and neuro anatomy by itself is fairly complex but learning it. Um I, I think over time uh is something that needs to be done. I think a lot of us go into neurology because we are lifelong learners. This is not something that you can learn during a pre course in medical school. It's not something that you can learn sometimes over the whole course of our career. So I think understanding the complexity, having a love for the complexity, recognizing that this may take time and then also thinking of what type of learner am I or as an educator who am I teaching? And what is my learner? Uh w what does my learner uh do to, to best uh advance what they're trying to understand. And we're very fortunate in today's world to have podcasts and to have technology that really supports our understanding of complex ideas. So I think that having resources, uh different visual resources, audio resources, some people learn by repetition. I think understanding your learning style and then looking for different resources and having resources at your fingertips can really make learning neuroanatomy a little bit easier. I think if I take it one step further, it's uh connecting it to something that might be a little bit more tangible. So even in preclinical years, even if you don't have a clinical correlation, learning through cases or learning through something that may be more relatable when it comes to neuroanatomy, I think is uh a very popular way to try to understand neuroanatomy. Uh a little bit more than just trying to copy down some figures from a textbook. Uh So I think all in all um it's a very complex thing to try to teach. I think that there should be some recognition uh in the complexity and some value in the complexity and, and learning that this may take time if you just kind of put this all out there. Uh right off the bat, it could be quite terrifying to be honest with you for a lot of people. And so I think that there needs to be realistic expectations going into what the learning goals are from a neuroanatomy standpoint. Um Some people you may have to oversimplify and some people might be more ready for some of the complexities of neuroanatomy. So I think taking it um in mind that, that every learner is a bit different, using a lot of the resources that we have in today's world to really uh speak to a lot of the different type of learning styles. Uh And then having people who are excited and passionate about teaching it uh are all ways that I think that we can make neuroanatomy uh a little bit less complex or at least able uh to digest it a little bit easier without making it too simple and losing that really uh beautiful aspect of, of why neuroanatomy is so complex. Absolutely. Well, I think that was a wonderful response and, you know, as you said, you have to stay up to date with the times and every single field of medicine requires you to be a lifelong learner. But I feel like the neurology aspect of it. Um Although as you said, neuroanatomy doesn't change over time, we should try to adapt the new modalities we have at our fingertips such as podcasts like this one that we're creating here today um to hopefully help students and resident doctors and attendings, get a better grasp of the material going forward. So thank you for that response, Doctor Boko, of course. So the ques the second question that I have um is for Doctor Trat. Um One of the most reported reasons for neophobia is limited exposure to neurological patients. However, neurological disease is often a primary cause of hospital admission or consultation. In 2011, it was reported that nearly 100 million Americans were diagnosed with neurological disease. And this number only continues to rise with our aging geriatric population. So, Doctor ETRA, what are the reasons behind limited neurology exposures even in the overwhelming presence of neurological disease? Um Thank you Napo uh for um having us out on this uh forum. Um And that's an interesting question and it uh uh speaks to this paradox where despite increasing uh patient population, people, you know, still complain that there may not be enough exposure uh to neurological patients. And some of that potentially goes back to early years in medical school where, you know, if you have that initial impression where neurology is difficult or neuroanatomy is tough, you know, that sets the mode, you know, for what's going to transpire after that, you know, once you create that initial impression, whether that's made when the student is, you know, going through basic neuroanatomy or the way it's being taught, uh if there is one student that has a bad experience or they find it tough, the word spreads pretty quickly and that tends to be the impression overall that, you know, that this is going to be tough no matter what. So, um you know, and, and then of course, the rotations themselves, uh you know, oftentimes the neurology experience is considered an elective and may not necessarily be a core rotation. So there might be many students who may not experience, you know, core neurology at all during their medical school, um like, you know, rotations. Um and then when they do have a rotation, um you know, the question comes, what kind of exposure or experience they're having? Is it a meaningful practical experience that they're having when they're rotating through their neurology, um you know, a month uh or weak or are they coming across, you know, uh different experiences where, you know, they are being asked, you know, questions which may not necessarily be very relevant from a practical perspective. I know for a fact, you know, historically, neurologists are known to be, you know, known to get involved into semantics, you know, so they ask a lot of questions about uh you know, what do you call this particular reflex? So what are the 55 names of this particular, you know, uh you know, uh examination findings. So how much of that is relevant in today's time? You know, when a lot of what we do is based on, you know, coming up with that diagnosis, a lot of it is based on, you know, how quickly you, you, you get to the answer, uh how quickly you treat somebody. Um So, so I think all of that sets a tone um where, you know, the, the experience for a medical student would be less than meaningful and that carries over into the future, you know, um experience as well once they're a resident or a fellow or a physician that doesn't go away because the, the ideas and the, the experiences that you carry over from a medical school, they're very, very strong, you know, a at, at that time period. Um you know, there, uh I, I would say that there is also additional onus on uh neurologists uh where, you know, if there is uh they have to do clerkship, you know, directorship or they have to be involved in uh creating their curriculum, how much time are they, you know, being allowed to do that, you know, how much time are they able to dedicate so that they can construct a meaningful experience for the students. Um You know, these days, uh it's, it's difficult to have that kind of dedicated time, you know, for physicians themselves to do that. Um So, so oftentimes that can be, you know, another factor that goes into that lesson, optimal experience for the medical student. Um Lastly, I think I would also mention the fact, you know, even when going, you know, into uh field as a fulltime physician, if it's a non neurologist, um there's a lot of reflexive neurology consultation on any issue that relates to the brain. Um You know, so, so, so it's just that carryover effect where the, um, the physician may not necessarily think about doing an initial investigation into neurological, you know, um, uh issues at first. Um, but rather than just reflexively consulting a neurologist and letting the neurologist deal with that, and we, as neurologists probably do a poor job where they, we don't, you know, we, we do our work and we just either sign off or just, you know, wither into space and not really communicating, um you know, with the, with the physicians and educating them about what the actual problem is or what could be done. So, so I feel that there are several factors there that can be, you know, attributed to why people feel that there's less than optimal neurology experience. Absolutely. I think that is such an honest and reflective response and it actually is a great segue into our next question, sort of this idea that physicians are, you know, overworked and they have a lot of clinical responsibilities. So to balance that with being a, an excellent teacher can also be difficult and, and that's seen not only on the side of the educator, feeling like they don't have the opportunity to educate the way that they would like, but also in the realm of students not feeling like they're getting the in that they're getting the sufficient teaching that they need to feel confident when it comes to the Neurosciences, both in a academic standpoint, as well as clinically speaking. And so, um you know, one of the other most reported reasons for neophobia is this idea of insufficient teaching of the material. And so, Doctor Kris, what are the most successful ways for students to incorporate the academic Neurosciences with clinical neurology? So it's uh I mean, you know, to Doctor Becker's earlier point, you know, you you can't practice neurology without at least a basic understanding of neuroanatomy. So unfortunately, that that does prove to be a stumbling block for some people. And you know, while orienting the initial instruction towards clinical aspects, does I think maintain interest? Otherwise, it does become very overwhelming just from a sheer detail perspective. Um But taking that and applying it to someone, you know, in the wild so to speak is, is where I think a lot of people stumble and um I had a, I had a conversation with uh uh Ethan Melzer who wrote uh which I, I love the title of this book. Uh How To Think like a neurologist, which I, I've been recommending to all of my students on rotations. And the first chapter is, is literally kind of like what we're talking about. It's like, how do I think about this? Like, how do I create the framework for approaching these patients and then taking that basic science understanding of like, well, it's such and such complaints that localizes to these possible locations based off of this timeline and the associated other comorbidities. I can create a nice framework and differential diagnosis and start kind of working through the differential in terms of like your, you know, can't miss diagnoses and your like most likely diagnoses and, and you know, in the grand scheme of things, avoid missing most things and getting to a diagnosis, maybe not the most efficiently, but in a fairly timely fashion, uh even with very basic neurologic skills. So, you know, I always like to say like, you know, what, what I do isn't really that hard. Mostly I'm just talking to people and asking questions. Uh you know, neurologists for the most part, aren't procedural list with, you know, obviously uh exceptions being to our IR colleagues and IC U uh colleagues. But a lot of what we do is just taking a, a long history and then, you know, working into that, you know, our physical exam to help refine our localization. Um which I, I was kind of interesting if, if people aren't familiar with the Bedside rounds podcast, I, I would recommend that one as well. He talks a lot about different log aspects and he says the physical exam is a procedure. I was like, well, I guess that kind of is true, right? We go into it with a certain hypothesis that we want to prove or disprove as it were and uh kind of synthesizing all that information together. And I think that in, you know, most classic neurology, that's a lot of what we're doing. Um where you're just, again, ultimately, like so much of medicine, it's pattern recognition. But identifying those patterns is, is kind of the the crux of the, the application of that basic neuroscience into a clinical framework. And uh having someone to guide you through that process is very important because it can be very daunting and, you know, you know, like doctor, it also mentioned, I think I saw a study, you know, the new Neurology Education Journal, which has been like, fantastic for the last couple of issues. Um I think they mentioned somewhere like between thirtyish percent of medical schools don't have neurology clerkships, which it's a huge percentage. Um And so like, I know I'm a, you know, ad o graduate, uh a lot of do schools don't necessarily have neurologists even on staff. And so you kind of have to seek it out. So if you already are intimidated by it, you're not necessarily going to go looking for more of it uh in many cases. So it does become this kind of like aversive uh feeling to neurology. I had 11 of my attendings always, you know, said just exactly like what doctor says, like it's a brain problem call neurology. You know, it's this black box, you know, uh that, that we cannot peer inside and we have to call them to kind of do their allies over it and uh decide what's going on and uh it does become this reflect of things. It's like, it's like all the patients, you know, very sick and they're confused. It's like, well, it's because they're very sick. Uh So sometimes you're not adding that much, but you are providing reassurance to the clinical team. And there, there usually is something for us to provide. Even if you know, as a consultant, it does become somewhat burdensome from time to time. But uh you know, it's always best e everything in life to approach it with a generous spirit. And uh just know that people are, are seeking out your opinion because they are uncomfortable or they, they think something is wrong and they're not quite sure what uh I know, I'm sure we've all gone to consults that we thought were going to be kind of nothing remarkable and then we get there and like, oh, this is actually a big deal and unfortunately, you're never quite sure unless you don't go and do the work. And so I know I've veered off topic uh somewhat from your original question. But uh but I think giving students that framework is going to carry into being residents, fellows attending. And so making sure that we as instructors take the time with medical students, which is, you know, as I'm sure a book can say it's not a traditionally compensated part of an academic position in many centers. Although I think that's shifting from what I've read uh in recent years but it, it is, it is something that you have to like volunteer for and spend additional time on in addition to your clinical duties or academic, you know, research duties. And, uh, it, it can be hard sometimes, especially if you're not at a larger medical school or an academic center to get that exposure. If you don't kind of seek it out, I'll stop my answer there. Well, thank you so much for that response and, and I, I think what you said was so applicable to the situation and, and when you were speaking about your own personal experiences of having the difficulty of getting that neurology exposure, I was relating to it severely since, as doctor knows, being an alumni of Northeast Ohio Medical University, as well as a lot of other universities in the US. Um exposure to neurology is limited and, and we need to have avenues as well as educators that are willing to put in the time and effort to help students get to where they wanna be. So I just wanna take a second to thank all of you. Um As you've all been, you know, a part of my journey along the way. And um I've learned so much from each one of you. And so it's, it's just a, a testament to how important it is to have passionate and involved educators when choosing a career path in medicine, but to shift gears a little bit. Um I wanted to talk about another article that actually Doctor Tko um brought to my attention where, you know, we earlier in this conversation, we've been talking about neurology, you know, and its complexity and how that can be very off-putting for a lot of individuals. But sort of paradoxically, even though this information is often complex, we sort of can't get enough of it. And so there was an article published in 2012 by Doctor Duran Fuller titled Neuro, a New Fascination for neurology, a new syndrome. And that found that even in the presence of neophobia, medical providers are still extremely interested in clinical neuroscience and this has been supported. Um because neurology is the most reported specialty in terms of published BMJ and lancet case reports relative to its burden of disease, which is only about 5% per that article. So, Doctor Beko, what is it about neurological disease? That is innately so fascinating. Yeah. Uh I I think if you ask a neurologist this question, we could probably have a whole uh series of podcast episodes on why we all love neurology so much. And you could probably get a very wide variety of answers. I think some things that stick out to me if you take this really complex world of neurology and this kind of brain mind behavior. How does it all intertwine? Um It's still I I think as doctor interest at a little bit of a black box, we don't know. Um and I think that there's some fascination in the unknown. Um, there is some fas fascination in complexity and intricacy. Um, and it, and it leads to a lot of, uh, really great academic discussion. I know that, uh, there's a lot of discussion within medicine as a whole in neurology. You know, I, I know that some of us are, are portrayed as, as kind of putting on our bowties sitting back in a big leather chair and just thinking, um and never really coming to a conclusion or to a meaningful response for a patient. I think that a lot of us that do what we do know that it's, it's different than that, but there is some truth to, to what's being said. And so there is some fascination in trying to understand something that's very difficult to wrap your head around. I would also say that some of the fascination um and, and what I see uh being involved in a residency program and, and watching, you know, kind of the growth of students to residents, to fellows to then uh full-fledged neurologist is that we have such a wide variety of subspecialties. Um I, I think that there's over 30 different subspecialties of neurologists uh of neurology that, that are reported uh within the last year or two. And that's just really remarkable. I've always said what other fields of careers can so many different type of people go into and be happy just as medicine in general. You can take so many different personalities of people, so many different uh people with different uh career objectives. And we're all in the same career. How amazing is that? And then if we narrow that down even more to neurology, you have the same thing within neurology, you have so many different personalities of neurologists, uh a, as a stroke neurologist, I guarantee you that uh I my personality is gonna be different than perhaps a neuromuscular neuro ologist or a headache neurologist. And uh I, I think doctor it, Trad and, and doctor Kenter is doing a lot of inpatient work very different than someone who's sitting in the office. And so I think it's really almost magical that we can take so many different people with so many different interests, but all a common interest in this complex unknown uh kind of brain and the interaction the brain has with the mind and the body. Uh a and if that's not magical and that, that doesn't make you think and, and wanna be a part of that, then I don't know what, what does I'll, I'll further it by saying that we're storytellers, neurologists are storytellers. Um uh We, we can't understate the, the history enough and what patients I think want from us a lot of times is to be able to have somebody who's gonna listen to their story. Um And so the fascination isn't just within the disease itself. It's in within that humanistic interaction that we have with our patients to where we actually have a chance to go and listen to different complaints that nobody can figure out that somebody just wants to say somebody wants to be heard. Um And we're storytellers and by being a good storyteller, you have to be a good listener as well. And so I think that there's some fascination in that, that part of it. Um a a as well. And I, I know that you're probably gonna ask me a couple more questions uh related to this article. And I thought that the article was beautifully written and part of the article mentions the, the very popular Show House, uh which a lot of us are very familiar with. And, and they actually did a little bit of a, a dive into the diagnoses that they presented on house and said that about 27% of all diagnoses were neuro uh primary neuro disorders. And I would argue that I actually went after I read this article and I looked at every single diagnosis that was made on house over the, the First Aid seasons. And um what, what I noticed is the 27% those were primary neuro disorders. Um I can't even begin to tell you how many have almost this end organ damage uh due to a systemic complication that leads to neuro disease also. And so I think that the fascination becomes whenever it changes who we are as people, when it changes our outward appearance, when it changes our uh approach to a conversation, because something neurologic is affecting us, other people see that more outwardly than if something is going on kind of beneath the surface. Uh And, and I think that there's something that draws people into neurology still because of, of all of those things. Absolutely. And so my follow up question to that is, you know, how do we reconcile this fascination, this innate fascination that people have with this growing fear for neurology? It's a good question. Um, and it's one that, that I think a lot of people think through quite a bit and, and how do we combine the two to come up to some happy medium where a lot of people can enjoy neurology or at least feel comfortable with it. Um, to be honest with you, uh, you know, in thinking through that the, the best answer I believe I can come up with myself. And I'd be curious to know what my, my colleagues think too, but I think that's, that you have to know that there's limitations and I think that there's a lot of power in saying that you don't know. And I think sometimes we, uh shy away from that and we get fearful as medical professionals because of the standard that we're held. Um, and we're supposed to be experts in our field and we have to know everything about everything uh that it's ok to say, I don't know. And going into neurology, I think that there's some, some empathy, there's some power, there's some compassion. I, I think that there's uh uh a, a very people call it the gray area. But I think it's, it's not necessarily great. It's maybe that we don't know um yet where, where we are in that area. But I think it's ok to say, I don't know. And so if you have some phobia, but you also have a love, I don't think that you have to not be scared of something to love it. I don't think that you have to know all the answers to be able to feel like you're an expert in something. And so I think uh kind of uh open arms uh kind of encompassing the, I don't know and being confident with what you do know and what you don't know. And also being able to relay that uh in a way to patients to where you can tell them that you don't know. But that, that's not the end of the, the line that just because you don't know, something doesn't mean that you won't continue to try to figure it out that you won't still be there for them. I think patients, one of the worst things that they wanna hear is there's nothing more that I can do for you. Um And so there's always something that we can do for our patients, there's always something we can do. First students, our residents, our, our ourselves, our colleagues. Um and, and so I think saying, I don't know, can, can be a very powerful tool in combining the, the unknown and the phobia part of neurology. Uh But then I don't know, but I'm going to go and try to figure this out. I'm going to continue to uh advance our field in ways that at some point in time, I hope that we have an answer for what we don't have an answer to now. And I think if you put those two things together, it can be very, very powerful. Absolutely. Doctor or Doctor Kras, would you like to elaborate on what Doctor Vala said? Sure. Uh You know, I, I, I can't count how many times in a week when I'm working in, in the hospital, I have to tell someone like, I don't know exactly what this is right. And you know, it uh I had, I had occasion to revisit some uh some of the classics this, this last year as so many people did during COVID uh old, old interest resurfaced. And I, I read Plato's Apology, you know, which like kind of like the famous or I should say one of the famous lines to paraphrases. The only thing I know is that I know nothing and it's like the more we learn, you know, every like this, this deluge of information coming up constantly in the Neurosciences and how that affects like diseases. That's, you know, uh you know, 10, 20 years ago were like essentially terminal diagnoses and now they're like, well, maybe we can treat that with gene therapy or, you know, you know, all these remarkable technologies that uh that didn't even exist. Um and certainly not in a clinical perspective, you know, even just a decade ago. So things, uh you know, the, the, the window keeps shifting in terms of what we do, understand what we can do. You know, I some of my older colleagues, you know, when they would diagnose someone with multiple sclerosis back in the eighties, it's like, well, you know, you're gonna be potentially in a wheelchair within a decade and there's nothing we can do to really slow it down. And, you know, now we have obviously that is not the case anymore for many people. And so we're, we're seeing this expansion into all of these uh previously thought to be incurable and treatable diseases and identifying more and more with more and more granularity, like what the underlying pathology is and all of these things that unfortunately to the, you know, the clinical eye might look very similar. And then we find that there's different underlying processes and we can, you know, it's very much getting into the era of like uh sort of uh designer therapies for many of these disorders. And it's uh it's both terrifying and as much as we think we know things and then we are proven so completely wrong and uh amazing. And as much as like there, there are treatments to being developed for all of these terrible disorders. So it's, uh it's certainly an amazing time to, to be a neurologist. I would say. Absolutely. I would just briefly comment, you know, one of my pet peeves here is, you know, oftentimes where we have this grab back category of diagnoses where we try to just fit in whatever we have into those. And oftentimes, you know, that's, that's, that leads to actually uh you know, a um a suboptimal experience for the observers of the students around you as well because, you know, you're trying to justify something when it doesn't meet, you know, what you were expecting to see with this particular, you know, diagnosis and then you're trying to just to fine and fit into that particular diagnosis. So I completely agree that at that point in time saying, I don't know and, but we can, you know, work on it and try to figure out, you know, is, is the best approach I would say in those situations. Absolutely. Well, thank you three for commenting on that. And it's also a great segue into our next question. You know, something that Doctor Kra said was this idea that the future is bright for neurology yet, although there's a lot to be discovered in terms of therapeutic modalities as well as these new pathologies in neurology, um we are still having a difficulty getting people into neurology in terms of the number of applicants and the overall shortage that we are facing as a country when it comes to neurology physicians. And so according to the Association of American Medical Colleges, there has been a 52% increase in neurology applicants since 2018. But the demand for neurologists still outweigh the supply available and there is a predicted 20% shortfall of neurologists by 2015. So, Doctor ETRA, besides neuropa, what are other factors that contribute to a neurology shortage in this country? Um Well, I would like to take some solace and the fact that there is an increase in the number of applicants uh which we always feel like isn't happening. But, but if we have statistics to back that up, then, then that's a good thing. Um You know, I would also preface that the number of referrals or not necessarily diagnoses, but need for neurologist is also increasing because the increasing number of testing, you know, compared to 20 years ago, uh you know, obviously imaging was not what it is now. And you know, there are much lower thresholds to order an MRI you know, on patients. Um and oftentimes there are incidental findings which lead to neurology referrals. So, so I think in terms of the need, when you look at the need and the growing need of neurologists, I think that is part of that equation that where that, you know, need for neurologist is coming from. Um, but at the same time, I think a lot of this goes back to what we, you know, discussed previously where, um, you know, when it's a less than meaningful experience for medical students at an early age, I mean, that may not necessarily be because of neuropa, but just because people are not really enthusiastic about going into neurology, you know, I think that would lead to a terms of uh neurologist down the road. Um You know, there's limited preclinical exposure to clinical neurology um where, you know it all you're doing is basic sciences. And instead of focusing on, you know, diagnoses and treatments, you know, a lot of stress is actually, you know, kind of put on uh just core neuroanatomy, which I'm not saying that is not important. But at the same time, I think the way to teach uh that is using a diagnose like a diagnosis based or a disease based model. Uh And then teaching neurone in that context rather than just teaching neuroanatomy, you know, as a dry subject, you know, oftentimes it's going to be more helpful. Um neurology as a practice is also something that is relatively less glorify, I would say um as opposed to some of the other specialties, um I know Blake mentioned about house where, you know, I think that's one show where I, I guess it is a bit glorified, but at the end of the Day house is not a neurologist himself. So, um, so there are, you know, there are specialties which are more procedure based. Um, you know, obviously, which are oftentimes a great pull or trigger for, um, you know, students and uh uh trainees to grab on and uh, like the idea of going into those kind of professions. Uh examples include, you know, obviously surgical specialties, cardiology, gastroenterology, you know, all of those are very, you know, heavily procedure based uh you know, specialties. So that could be one part of the reason where while in neurology, there are, you know, areas where there is procedure, you know, procedure uh uh based specialties like neural neural, it EMG s and things like that. But as a whole, when somebody thinks about a neurologist, you know, generally they're thinking about somebody who's seeing patients in the office. Uh and I'm not doing a lot of these procedures. So, so I feel that kind of oftentimes is another reason and that's just the basic, you know, understanding that a lot of people have. Um II I don't think we can uh have a complete conversation without mentioning pay, you know, so compensation wise, um if you look at the, you know, top 2025 specialties within medicine, uh neurology is not among the top 10, you know, according to most surveys in terms of their compensation. So, so that's one additional factor when you combine the underlying, you know, difficulty with the topic itself. Um, and, uh, looking at, you know, something which has relatively less procedures. Um And then when you combine that with, you know, where people say, hey, you know, it doesn't, also doesn't pay me that well, then that definitely adds to, to that uh kind of uh ex sodas, so to speak, you know, of pe of students uh away from neurology. Um a a and you know, again, expanding those points about uh you know, when people think about neurology or neurologists, they tend to think that they're people who diagnose but don't treat which we know as neurologist is definitely not true. Uh you know, there are treatment options and there are management options available for essentially old diseases. So, so it's not just the actual, you know, pill or the pharmacological agent that you have to administer, but there's so many things beyond that that require a neurologist which and there are things which only a neurologist can do, which other specialties or other uh you know, uh members cannot do. Um And then, you know, just talking about treatment options as doctor Kris had mentioned that things like MS for example, you know, we did not have a lot of treatment options back in the eighties. But look at now, you know, we, we have 20 or so, you know, readily available, you know, treatment options for patients. We have expanded the use of uh you know, antibody uh or targeted, you know, agents uh specifically for uh MS um uh and antibody targeted uh treatments for migraines. Um you know, um there are genetic treatments that are available. So, so it's, it's definitely changed uh you know, in that spectrum over time. So, so I think, but, but just the opinion and, and that knowledge may not be commonplace. So all the more reason why stress on disease and management uh earlier on in the, in the uh medical school curriculum is, is one key in this situation. Absolutely. And I, while we can't necessarily change the compensation or, or the other factors that neurologists struggle with on their way to becoming excellent physicians. One thing that we can discuss and possibly help to fix is this prevalence of neophobia. And so, um in your opinion, Doctor Kris, what is the most effective way to eradicate neophobia? So uh before I jump into that, I will say uh to doctor s point about pay, it is currently, I think the second most in demand specialty. So if you are going to neurology, don't be afraid to negotiate your contract because they need you more than you need them. But uh with respect to neophobia, you know, uh I think a lot of what we've talked about uh so far in this conversation are, are kind of the ways, you know, the best way to fight something you're afraid of is to become more familiar with it. Um In terms of what uh you know, ne like clinical neurologist should be doing is is taking an active role in like, you know, be involved with your local medical school, take, take students uh for rotations, get people that's that hands on clinical experience to familiarize themselves with, with neurology and the practice of neurology, even if it was even or even more importantly, if they're not going into neurology. Um you know, obviously, if you're gonna do a neurology residency, you're gonna get exposure, but for the people who are going into like internal medicine or family or some other specialty altogether, you know, this might be the only time in their career. And, you know, I think about where I am now. Uh So, you know, previously I was, I was faculty at right state and, you know, I had a neurology residence and a clerkship and, you know, we moved closer to family. And so now I'm like one of the only neurologists in a 50 mile radius. And, uh you know, it's obviously much different uh in terms of not just the neurology knowledge of the or the exposure of the students, but also the faculty and the other attendings in the area, right? They're used to the neurologist who have been here for 2030 years and, you know, you kind of wind up in a little insulated bubble per se in terms of some of the practice and so not just educating students, but also the residents if they're, you know, willing or even unwilling to do rotations with you. Uh And the faculty, you know, I always think um well, nobody likes documentation, you know, I always think the the classic reasons for, for writing in general, right, to inform, to educate and perhaps even in the medical record, to delight. Um but the uh every, every interaction is a potential opportunity, you know, for, for spreading the gospel neurology uh potentially. So I think approaching it with that perspective, which, you know, it can be hard when you're feeling tired and run down. But uh but trying to, to be that, you know, reach for that ideal neurologist in your mind and try and aspire to better practice. Uh But I think just always being willing to, to discuss things to, to talk through things, uh you know, not being that kind of like the old stereotype of, you know, the, the very short Brusk attending who's like, well, why are we doing this? Because I said so, right, that's, that doesn't help anybody. And in reality, even if you just approach it from kind of a, a rational selfishness perspective, they're just gonna call you again. So why not explain it now? Uh and hopefully educate people so that, you know, maybe you are in an area where there aren't enough neurologists, but educating your, your, you know, hospitalists and PC PS in the area might help with the quality of the referrals or the workup that's been done before the patient shows up in your clinic. So I think uh approaching it from, from all these angles is important. And, you know, like Doctor Baleka mentioned earlier, we do have, you know, venues like this. Um We're able to do, you know, lectures, uh you know, asynchronously uh teleconferences with people like across the country. So there's, there's so many ways that we can become involved with education. Uh I know for the last two years, I've been doing uh lecture series for the psychiatry residents in akin. And, you know, I haven't driven through Arin in probably six months, but still, you know, it's something that we do and, you know, we, we do see like there, there's, you know, their inservice scores go up in the clinical neurology section and things like this. So, you know, it, it benefits us all uh to know a little bit more about the areas that we interface with on a regular basis. So I think, I think making that effort to reach out to, to look in your community. Where are the areas that are deficient? Where are you seeing the problem referrals coming from and reaching out to those areas? Like, hey, you know, I'd love to do some, you know, talks with your residents or, you know, with faculty or, you know, kind, you know, uh which, you know, can be hard, you don't want to offend anyone's pride. But uh I think it's, if it's given in a, a good spirit, it usually is received in such as well. So I would say that's, that's kind of my approach to it, at least. Absolutely. I think that's, that's a great approach. And it goes back to that, that saying of you can give a man a fish. But if you teach him how to fish, um the results are a lot more beneficial. And so thank you for that for that insight. Doctor and, and Doctor Valeo and doctor it. Um I, I wanted to brought in this question to also include the two of you, you know, how are, how are you guys accomplishing this task of trying to eradicate neuropa in your own medical practices? So, um you know, I can, I can start first um basically, um just kind of laying out uh a sort of uh in, in, you know, basically your own mind, you know, what kind of uh a setup you want or what kind of other core kind of disease or diagnosis that students who are rotating on the service or uh the rotators that come on your service uh from other specialties like internal medicine. Um You know, what, what I tend to envision is you, you know, what are the things that they're going to encounter even if they don't go on to become neurologist, you know, down the road? What are the core skill that they would need, you know, from that perspective. So, you know, having that set of diagnoses, like, you know, headaches, strokes, uh you know, tremors, uh seizures, obviously, you know, so some, some of the common things which I would like them to be empowered to treat by at least initiate their basic, you know, management or develop a plan. And then obviously, if it becomes more complicated outside of that, then they can refer, you know, to a neurologist. I think, I think that's basically my sort of uh you know, way to approach things. So having a sort of a core curriculum aro around those things and ma making sure that whoever comes on service gets uh exposure to that variety of diagnoses. Again, I don't necessarily want them to be seeing, you know, things that are very rare. Uh you know, uh again, although we see those, but, you know, that's good from an academic perspective. But I think overall asking questions and bringing up, you know, conversations about common things and how, you know, you would diagnose and what the uncommon presentations of common disease or diagnoses and then kind of working on, you know, uh developing a plan and management strategies for something like that. Um You know, I think that's the approach that I usually take in terms of ensuring that, that uh that they remain focused and interested, you know, and again, down the road, they're able to use those practical skills. Um And then obviously, if there is medical students like you who are more interested than, you know, obviously the, the discussions and conversation is slightly different. Um, as you know, so, um, but uh, but definitely something that, uh we, we wanna look at a broader picture here. So, yeah, I ca I can't agree with everything that's already been said. I, I won't uh add, add too much, but I have a couple maybe thoughts that uh might tie some of this together in an unconventional way. One, I think that we need to implement a pyramid scheme. It's as simple as that. Uh And, and what do I mean by this? If, if I can light the neurology fire in two people and both of those two people go and light the neurology fire in two or three other people. Then all of a sudden uh we have this, this uh kind of sweeping model of kind of invigorating neurology and, and this neuro into people more than neophobia and neophobia happens in, in the same way we talked about that earlier where one person says, oh my gosh, neurology is so scary and, and it's so intimidating and it's so complex. And II I didn't wrap my head around this and then they spread that to the next class and the next class. But where are the voices of the people who love it? Where is the neuro at? It's out there? It's been published on, you're doing a podcast on it. We are all here. Um I think that it, it just takes reminding people that, you know, I love what I do. I would not change anything uh about what I do. I, I love being a neurologist. This is a childhood dream come true for me. Um And this is something that I is a big part of who I am. And I think nowadays in medicine, with medicine, changing uh in the field of medicine, changing change isn't always bad. And I think we always focus on the change that may not be the most positive. But I think we as neurologists need to remind people that we love what we do. We love storytelling, we love uh the advances that are being made. And I think if we can share what we love about neurology more than what we can do to, to continue to facilitate this neuropa with all the resources that we have. Um I think that that's how we eradicate neophobia. I think it's being patient, knowing limitations, uh setting expectations with learners and understanding your learners. Um And then reminding people that we love what we do. We love coming into contact with people who also love neurology. Uh We're a very small community and uh even as, as faculty attendings, uh we all rely on each other, we are all very collegial and collaborative. And I think that there's something to be said about being in a community that really works together for similar goals. And so if we can spread that, um more so than, than what the neuropa gets spread, then I think that we're doing everything that we can. Absolutely. Well, I just wanna once again, thank all three of you, Doctor Blake Tko, Doctor Ahmed ETRA, as well as Doctor Michael Kris for taking the time to provide such insightful perspectives regarding the topic of neuropa as well as neuro. Um I'm sure that our listeners will learn so much from this episode as I know I have already. And if you are hearing this message, you have listened to the entire episode and for that, we want to thank you from the bottom of our hearts. We hope you enjoy this episode. And if you did, please leave us a review and share this episode with a friend, make sure you follow us on our social media at Neophilia Pod for updates on future episodes. See you next time.