Benbadis, Selim

Beniczky, Sándor

Fasano, Rebecca

Fountain, Nathan B

Friedman, Daniel

Gavvala, Jay R

Jing, Jin

Kaplan, Peter W

Karakis, Ioannis

Maheshwari, Atul

Nascimento, Fábio A

Ng, Marcus

O\u27Donovan, Cormac

Perry, M Scott

Rampp, Stefan

Rao, Vikram R

Schomer, Donald

Sheikh, Irfan S

Sinha, Saurabh R

Sperling, Michael R

Strowd, Roy

Tankisi, Hatice

Tanner, Adriana

Vinayan, K P

Weber, Dan

Westover, M Brandon

Wilmshurst, Jo M

Wirrell, Elaine

Yacubian, Elza M

Yuan, Fang

English

DigitalCommons@The Texas Medical Center

Competency-based EEG education: a list of “must-know” EEG findings for adult and child neurology residentsFábio A. Nascimento1,2, Jin Jing1, Roy Strowd3, Irfan S. Sheikh1, Dan Weber4, Jay R. Gavvala5, Atul Maheshwari5, Adriana Tanner6, Marcus Ng7, K. P. Vinayan8, Saurabh R. Sinha9, Elza M. Yacubian10, Vikram R. Rao11, M. Scott Perry12, Nathan B. Fountain13, Ioannis Karakis14, Elaine Wirrell15, Fang Yuan16, Daniel Friedman17, Hatice Tankisi18,19, Stefan Rampp20, Rebecca Fasano14, Jo M. Wilmshurst21, Cormac O’Donovan3, Donald Schomer22, Peter W. Kaplan23, Michael R. Sperling24, Selim Benbadis25, M. Brandon Westover1, Sándor Beniczky18,191Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA2Department of Neurology, Washington University School of Medicine, St. Louis, MO, USA3Department of Neurology, Wake Forest University School of Medicine, Winston-Salem, NC, USA4Department of Neurology, Saint Louis University, Saint Louis, MO, USA5Department of Neurology, Baylor College of Medicine, Houston, TX, USA6Mercy Health, Grand Rapids, MI, USA7Section of Neurology, University of Manitoba, Winnipeg, MB, Canada8Department of Pediatric Neurology and Advanced Center for Epilepsy, Amrita Institute of Medical Sciences, Cochin, Kerala, India9Department of Neurology, University of Pennsylvania Perelman School of Medicine, Philadeplhia, PA, USA10Department of Neurology and Neurosurgery, Universidade Federal de São Paulo, São Paulo, Brazil11Department of Neurology and Weill Institute for Neurosciences, University of California, San Francisco, California, USA12Jane and John Justin Neurosciences Center, Cook Children’s Health Care System, Fort Worth, TX, USA13Department of Neurology, University of Virginia, Charlottesville, VA, USA14Department of Neurology, Emory University School of Medicine, Atlanta, GA, USA15Department of Neurology, Mayo Clinic, Rochester, MN, USACorrespondence: Fábio Augusto Nascimento e Silva, Campus Box 8111, 660 South Euclid Avenue. St. Louis, MO, 63110, USA, < nascimento.fabio.a@gmail.com>, < fabion@wustl.edu>. Supplementary material.Supplementary data accompanying the manuscript are available at www.epilepticdisorders.com. e-Survey utilized in the study.HHS Public AccessAuthor manuscriptEpileptic Disord. Author manuscript; available in PMC 2023 January 04.Published in final edited form as:Epileptic Disord. 2022 October 01; 24(5): 979–982. doi:10.1684/epd.2022.1476.Author ManuscriptAuthor ManuscriptAuthor ManuscriptAuthor Manuscript16Department of Neurocritical Care, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, China17Department of Neurology, New York University Grossman School of Medicine, New York, NY, USA18Member of the European Reference Network EpiCARE, Department of Clinical Neurophysiology, Aarhus University Hospital, Aarhus Denmark19Member of the European Reference Network EpiCARE, Department of Clinical Neurophysiology, Danish Epilepsy Center, Dianalund, Denmark20Department of Neurosurgery, University Hospital Erlangen, Erlangen, Germany and Department of Neurosurgery, University Hospital Halle (Saale), Germany21Department of Pediatric Neurology, Red Cross War Memorial Children’s Hospital, Neuroscience Institute, University of Cape Town, Cape Town, South Africa22Department of Neurology, Beth Israel Deaconess Medical Center, Boston, MA, USA23Department of Neurology, Johns Hopkins University, Baltimore, MD, USA24Department of Neurology, Thomas Jefferson University, Philadelphia, PA, USA25Member of the European Reference Network EpiCARE, Department of Neurology, University of South Florida, Tampa, FL, USAThe competency-based model has been guiding medical education on an international level over the last decades [1]. This model is learner-centered and has mastery of specific knowledge and skills as its unit of progression [2]. In the realm of electroencephalography (EEG), there have been continued efforts to ensure that residents have the competence to accurately and reliably interpret EEGs by the time they complete residency training. Achieving this goal is imperative, especially in countries where EEGs are typically read by neurologists without clinical neurophysiology or epilepsy fellowship training [3, 4], due to the deleterious consequences of EEG misinterpretation and epilepsy misdiagnosis [3]. In an attempt to define minimum EEG competency milestones, we herein propose a prioritized list of routine EEG findings that all adult and child neurology residents should be able to identify and interpret on completion of training.Resident EEG education is guided by well-formulated milestones proposed by organizations such as the Accreditation Council for Graduate Medical Education (ACGME) [5] and International League Against Epilepsy (ILAE) [6]. These milestones, however, are not meant to be used to determine whether a trainee is competent to graduate; additionally, the milestones do not specify particular EEG findings that should be mastered by trainees. For example, the ACGME EEG Level 3 milestone encapsulates recognition of “common EEG abnormalities”; these “abnormalities”, nonetheless, are not specified. We surveyed a group of EEG/epilepsy experts to delineate a list of routine EEG findings rated by their clinical yield for adult and child neurology resident education.Nascimento et al. Page 2Epileptic Disord. Author manuscript; available in PMC 2023 January 04.Author ManuscriptAuthor ManuscriptAuthor ManuscriptAuthor ManuscriptThe authors (FN, JJ, MBW, SB) designed an online survey (see supplementary material) in which a comprehensive set of adult and pediatric routine EEG findings were listed under four major sections: normal findings, artifacts, normal variants, and abnormal findings. Neonatal EEG findings were not included. EEG/epilepsy experts were asked to rate each EEG finding on a 5-point Likert rating scale (1 = “not at all important”, 5 = “extremely important”) based on the importance for adult and child neurology residents to learn this finding during residency training. We applied different weights to each answer corresponding to its respective point per the 5-point Likert rating scale (e.g., a weight of 5 for 5 points on the Likert scale = “extremely important”), and generated a single weighted mean for each finding. Further, we asked experts for their rationale in rating each EEG finding. Data collection was performed from April to May 2022. All data is available upon request. Twenty-six EEG/epilepsy experts completed the survey from the following countries: the USA (n=19), Denmark (n=2), Canada (n=1), Germany (n=1), Brazil (n=1), China (n=1), and India (n=1). All experts practice either in an academic setting (n=24/26; 92%) or combined academic-private setting (n=2/26; 8%). The mean number of years reading EEGs (including during clinical neurophysiology or epilepsy fellowship training) among experts was 20 years (range: 2–47 years). EEG findings and their respective weighted mean scores are shown in table 1.Experts rated EEG findings based on whether their misinterpretation would lead to unnecessary treatments (n=24/26; 92%), additional unnecessary tests (n=23/26; 88%), or epilepsy misdiagnoses (n=22/26; 85%). Free text responses were evaluated and included rating the relative importance of EEG findings depending on the prevalence of the findings in clinical practice (n=1/26), their presence in previous examinations assessing EEG competency after residency graduation (n=1/26), and the expert’s previous learning experience while a resident (n=1/26). One expert stated that “if a neurologist has to interpret EEG after graduation, additional training is essential” whereas another expert noted that “all topics need to be known by an EEG specialist [reader] including a neurology resident”.Despite neurology residents’ high motivation to learn EEG [7, 8], both their level of confidence in interpreting EEG independently [7–10] and their objective knowledge of EEG [8] are far from optimal. In a survey of USA adult neurology residencies, program directors reported that this educational gap is a result of insufficient EEG exposure and ineffective didactics [11]. We believe that a key factor contributing to these education barriers arises from a lack of objective, well-defined EEG competencies expected of graduating residents including the absence of a recognized list of “must-know” EEG findings. Our study provides such a list which includes an inventory of routine EEG findings generated based upon opinions of a large group of multinational EEG/epilepsy experts who practice academic epileptology.We believe that this resource addresses several challenges associated with trainee EEG education. First, our list of “must-know” routine EEG findings may be used in combination with broader milestones (such as those proposed by the ACGME [5] and ILAE [6]) to help residency programs create consistent, specific, attainable EEG learning milestones. These benchmarks may be used to develop milestone-based curricula and, ultimately, a roadmap for resident EEG training. Moreover, these milestones may be used as assessment standards; Nascimento et al. Page 3Epileptic Disord. Author manuscript; available in PMC 2023 January 04.Author ManuscriptAuthor ManuscriptAuthor ManuscriptAuthor Manuscriptin other words, to evaluate residents’ EEG competence longitudinally throughout residency training.Second, this resource may be helpful in prioritizing EEG findings that must be learned during residency training. Similarly, by using the above-mentioned milestone-based assessment standards, programs may adjust quality and quantity of resident EEG exposure to achieve the level of proficiency in EEG required by completion of residency training. This aspect may be especially beneficial given the pervasive problem of insufficient EEG exposure, a well-known barrier to resident EEG education [11]. Survey data from USA adult neurology program directors showed that residents are required to undergo an average of 1.7 one-month EEG rotations to graduate (range: 0–4), and these trainees typically read zero to 30 EEGs per rotation [11]. Given this relatively small amount of dedicated EEG learning time, we believe that residents should focus on those EEG findings that have the greatest clinical yield – those findings that, if misread, might result in unnecessary treatments, tests, or epilepsy misdiagnoses. Residency programs could create educational libraries containing anonymized examples of high-yield EEG findings to ensure that residents are exposed to all of these essential EEG findings during their training. Lastly, using a comparable list of EEG findings to teach residents and assess their competency might serve research purposes, allowing a more valid comparison of trainee data from different institutions and different countries.We hope that this list of routine EEG findings has the potential to make the adult and child neurology resident EEG learning process more objective and standardized, which - as a result - may be educationally beneficial to both teachers and trainees.Supplementary MaterialRefer to Web version on PubMed Central for supplementary material.Disclosures.F. Nascimento is an Associate Editor of Epileptic Disorders. R. Strowd serves as a consultant for Monteris Medical Inc., and receives an editorial stipend as Section Editor of the Resident and Fellow Section of Neurology. R. Strowd has received research grant support from the American Academy of Neurology, American Society of Clinical Oncology, Southeastern Brain Tumor Foundation, and Jazz Pharmaceuticals and has received royalties from Elsevier, Kaplan, and Lecturio. D. Weber is a speaker for SK Life Sciences. S. Sinha serves on the Board of the American Board of Clinical Neurophysiology. S. Beniczky is Editor-in-Chief of Epileptic Disorders. All other authors report no disclosures relevant to this manuscript.References1. McGaghie WC, Miller GE, Sajid AW, Telder TV. Competency-based curriculum development in medical education: an introduction. Public Health Pap 1978; 68: 11–91.2. Sullivan RL. The competency-based approach to training. Strategy Paper No 1. Baltimore, Maryland: JHPIEGO Corporation, 1995.3. Benbadis SR. Errors in EEG and the misdiagnosis of epilepsy: importance, causes, consequences, and proposed remedies. Epilepsy Behav 2007; 11: 257–62. [PubMed: 17719853] 4. Adornato BT, Drogan O, Thoresen P, Coleman M, Henderson VW, Henry KA, et al. The practice of neurology, 2000–2010: report of the AAN member subcommittee. Neurology 2011; 77: 1921–8. [PubMed: 22031533] Nascimento et al. Page 4Epileptic Disord. Author manuscript; available in PMC 2023 January 04.Author ManuscriptAuthor ManuscriptAuthor ManuscriptAuthor Manuscript5. The Accreditation Council for Graduate Medical Education. Neurology milestones. ACGME, 2021. www.acgme.org/globalassets/pdfs/milestones/neurologymilestones.pdf6. Blumcke I, Arzimanoglou A, Beniczky S, Wiebe S. Roadmap for a competency-based educational curriculum in epileptology: report of the Epilepsy Education Task Force of the International League Against Epilepsy. Epileptic Disord. 2019; 21: 129–40. [PubMed: 30892268] 7. Daniello KM, Weber DJ. Education research: the current state of neurophysiology education in selected neurology residency programs. Neurology 2018; 90: 708–11. [PubMed: 29632112] 8. Nascimento FA, Maheshwari A, Chu J, Gavvala JR. EEG education in neurology residency: background knowledge and focal challenges. Epileptic Disord 2020; 22: 769–74. [PubMed: 33399093] 9. Mahajan A, Cahill C, Sharf E, Gupta S, Ahrens S, Joe E, et al. Neurology residency training in 2017: a survey of preparation, perspectives, and plans. Neurology 2019; 92: 76–83. [PubMed: 30518554] 10. Lourenco ES, Kowacs DP, Gavvala JR, Kowacs PA, Nascimento FA. EEG education in Brazil: a national survey of adult neurology residents. Arq Neuropsiquiatr 2022; 80: 43–7. [PubMed: 34755770] 11. Nascimento FA, Gavvala JR. Education research: neurology resident EEG education: a survey of US neurology residency program directors. Neurology 2021; 96: 821–82. [PubMed: 33310878] Nascimento et al. Page 5Epileptic Disord. Author manuscript; available in PMC 2023 January 04.Author ManuscriptAuthor ManuscriptAuthor ManuscriptAuthor ManuscriptAuthor ManuscriptAuthor ManuscriptAuthor ManuscriptAuthor ManuscriptNascimento et al. Page 6Table 1.Survey data outlining routine EEG findings per major category (normal findings, artifacts, normal variants, and abnormal findings) and their respective weighted mean scores based on EEG/epilepsy expert scoring (1 = “not at all important”, 5 = ”extremely important”).Normal findingsArtifactsNormal variantsAbnormal findings•Awake, adult PDR (4.77)•Awake, pediatric PDR (4.58)•Drowsiness, slowing of PDR (4.58)•Stage 2 sleep, sleep spindles (4.46)•Stage 2 sleep, K complexes (4.42)•Drowsiness, diffuse irregular delta-theta slowing of background (4.42)•Stage 1/2 sleep, vertex waves (4.42)•Drowsiness, slow roving lateral eye movements (4.23)•Stage 1/2 sleep, POSTS (4.23)•Stage 3 sleep, diffuse irregular delta slowing (4.19)•Rapid eye movement (REM) sleep, erratic eye movements (3.85)•Rapid eye movement (REM) sleep, sawtooth waves (3.12)•EKG (4.58)•Eye blinks (4.54)•Electrode pop (4.46)•Myogenic (4.42)•Eye fluttering (4.38)•Lateral eye movements (4.31)•60-/50-Hz artifact (4.23)•Pulse (4.15)•Lateral rectus spikes (4.12)•Chewing/bruxism (4.04)•Sweat (3.92)•Glossokinetic (3.77)•Nystagmus (3.65)•Respiration/breathing (3.62)•Wickets (4.35)•Hyperventilation-induced slowing (4.19)•Small sharp spikes (4.19)•Breach (4.12)•Rhythmic mid-temporal theta of drowsiness (4.08)•Hypnopompic hypersynchrony (3.92)•Hypnagogic hypersynchrony (3.92)•Photic driving (3.85)•Mu rhythm (3.81)•Posterior slow waves of youth (3.81)•Photomyogenic response (3.81)•Lambda waves (3.73)•Temporal slowing of the elderly (3.69)•Slow alpha variant (3.50)•6 Hz phantom spikes (3.50)•Frontal arousal rhythm (3.42)•14-and-6 Hz positive spikes (3.42)•Increased frontal beta activity (3.38)•Subclinical rhythmic electrographic discharges in adults (3.35)•Fast alpha variant (3.31)•Midline central theta (Ciganek rhythm) (3.23)•Occipital needle-like spikes of blindness (3.08)•Slow fused transient (2.96)•Fronto-central rhythm (texting rhythm) (2.73)•Generalized epileptiform discharge, 3 Hz (4.81)•Generalized epileptiform discharge, 3–5 Hz, polyspike (4.77)•Focal seizure (4.77)•Focal epileptiform discharge, spike (4.73)•Focal epileptiform discharge, sharp (4.73)•Generalized seizure, absence (4.73)•Generalized epileptiform discharge, <2.5 Hz (4.69)•Focal epileptiform polyspike (4.65)•Generalized seizure, tonic (4.62)•Infantile spasm (4.35)•Hypsarrhythmia (4.35)•Focal irregular/polymorphic slowing (4.27)•Focal regular/rhythmic slowing (4.23)•Diffuse irregular/polymorphic slowing (4.15)•Diffuse regular/rhythmic slowing (4.15)•Abnormal PDR, slow for age (4.00)•Abnormal PDR, asymmetric (4.00)•Asymmetric sleep spindles (3.73)Epileptic Disord. Author manuscript; available in PMC 2023 January 04.Author ManuscriptAuthor ManuscriptAuthor ManuscriptAuthor ManuscriptNascimento et al. Page 7PDR: posterior dominant rhythm; POSTS: positive occipital sharp transients of sleep.Epileptic Disord. Author manuscript; available in PMC 2023 January 04.

Competency-Based EEG Education: A List of “Must-Know” EEG Findings for Adult and Child Neurology Residents

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Competency-Based EEG Education: A List of “Must-Know” EEG Findings for Adult and Child Neurology Residents

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