Episode 12: Sustaining Purpose over a Lifetime with Dr. Ralph F. Józefowicz, MD

What does it take to sustain a meaningful, impactful career in neurology education over decades? This month, I am joined by legendary neurology educator Dr. Ralph F. Józefowicz, MD, a pioneer clinician educator in neurology and a giant in our field. We discuss his lifelong passion for neurology education, his advice for “becoming the best” in education administration and leadership, and his international educational partnership with Jagiellonian University in Poland. 

Plus, a spooky twist for the month of Halloween: listen through to hear the origin story behind how Dr. Józefowicz coined the now infamous term, “neurophobia.” 

Dr. Józefowicz is Professor of Neurology and Medicine and Associate Chair for Education in the Department of Neurology at the University of Rochester. Previously, he served as the Neurology Residency Program Director between 1996-2021, the third-year Neurology Clerkship Director from 1994-2019, and the director of the Mind, Brain and Behavior preclinical neurosciences course between 1998-2020. In 2003 he was made an Honorary Professor at Jagiellonian University in Krakow, Poland, one of the oldest Universities in Europe.

Neuropraxis: The Neurology Educator's Podcast is not recorded as an official podcast of any institution or organization. The views and opinions are those of the individual speakers themselves. Music from Pixabay. Cover art by Carolin Wollny. Editing by Valeria Roldan. New episodes drop first Monday of the month!

Ideas, suggestions, questions? Contact us at neuropraxispodcast@gmail.com. 

Transcript

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SPEAKER_02 0:01

Hello and welcome to Neuropraxis, a podcast for clinician educators and trainees passionate about neurology education. I'm your host, Glena Gaikan. I'm a neurologist and medical educator. On the Neuropraxis podcast, we turn our attention to neurology education. We discuss the latest topics in education literature, meet the innovators shaping the future of neurology education, and hear about the career journeys of other educators in neurology. Whether you're building a career in medical education or looking for inspiration in your teaching, you're part of our community. So let's reflect and grow together as we blend the art and science of neurology education and put theory into praxis. Welcome back to the Neuropraxis Podcast. Today I speak with Ralph Joseph Witchwick, professor of neurology and medicine, and associate chair for education in the Department of Neurology at the University of Rochester. He was the former residency program director, the former clerkship director, and the former director of the preclinical neurosciences course, Mind Brain and Behavior. We talk about Ralph's pioneering career as a clinician educator in neurology, his advice for education, administration, leadership, and sustainability, and the origin story behind how he coined the now infamous term neurophobia. Listen to learn more from one of the giants in our field. Hello everyone and welcome back to the Neuropraxis Podcast. I'm extremely excited for the conversation this morning. I'll be talking with Ralph Josefowitz Dr. Ralph Josefowicz is a professor of neurology and medicine and associate chair for education in the Department of Neurology at the University of Rochester, where he served as the residency program director between 1996 and 2021. He also served as the director for the second-year medical student course between 1998 and 2020, and the third-year neurology clerkship between 1994 and 2019. In 2003, he was made an honorary professor at Jagelion University in Krakow, Poland, where he's been doing international education work for over 30 years.

unknown 2:38

Dr.

SPEAKER_02 2:38

Ralf Trzefowicz has had numerous leadership positions in national medical societies, served on numerous boards of directors, has received dozens of lifetime achievement awards in education, and is truly one of the leaders in our field. Dr. Ralph Trosewicz, welcome to the podcast.

SPEAKER_00 2:57

Thank you very much, Clean. I'm very much looking forward to speaking to you.

SPEAKER_02 3:01

You know, it was just incredible to read through your life story or a career story at the very least, and just see all the many ways in which you were the first to do so many of the things that we talk about now as regular and you know standard within the clinician educator career. So I'm so excited to hear from you, but kind of going back to the beginning and where it all started. I was wondering if you could tell us a little bit about your career journey so far, just kind of the big milestones along the way and the roadmap, and then we'll return to each of them in turn.

SPEAKER_00 3:37

Well, I was always interested in teaching and education, uh, even in high school and in college, but in medical school is when I uh really enjoyed teaching the junior students, especially when I was I was a fourth-year student. And then when I began uh residency, uh I really enjoyed teaching the uh junior residents, and uh when we would be on call and at the end of the day we would go through each patient, try to localize lesions and come up with a differential diagnosis. And I had a knack for basically keeping things organized and simplified. However, at that time, um the only way you could become successful in academic medicine is by doing research and uh getting grants and publishing papers. And I tried this. I actually had a uh fellowship in neuromuscular diseases, one year was a research fellowship, and I just quickly decided that was not for me. But I wanted to stay in academics and become a teacher. Luckily, I uh had great mentors. Uh Bob Joint was my first chair, and then Birch Griggs, and both of them supported my career as an educator. In fact, uh Birch Griggs got me a grant once uh that I did not want to accept, a research grant. And at one point he called me into his office and he said, Joseph Witz, you teach this much, too much. And if you continue to teach this much, you're never going to be successful. That's exactly what he told me. But I told him I want to teach, and I convinced him, and he supported me as a teacher, and he mentions that's that was one of the best decisions he ever made. So the point was that I knew what I wanted to do. And uh the question is how do you become successful as an educator when in the old days to be successful in academics you had to publish and get grants? Well, I once heard Marty Samuels talk about the equalization of all of the uh uh promotion tracks, and the main thing that equalizes the research track, the clinical track, and the education track is stature. And stature is very important. And if you want to basically be successful as an educator, you have to have, as an assistant professor, you have to be a local expert. Associate professor, you need to be developing national expertise, and a full professor, you have to be a national expert and have international exposure. And that basically means uh being involved in national committees, uh meeting a lot of people, giving talks around the country, and then developing curricula that you could share with individuals in other medical schools and other residency programs. And that's what I basically pursued. Why did I do it? Not because I wanted basically stature and accolades, but because I really felt there was a need to develop good teaching in neurology in medical schools and in residency programs, and I wanted to share this, and also I wanted to mentor young uh educators around the country. And I think I've been successful in doing that over the years.

SPEAKER_02 6:50

I would agree with you. I think it has been an absolute success. And I I was gonna ask, like, whether what it's like for you to now sit at conferences where there's a discussion of the role of the clinician educator, the career path of a clinician educator, did those terms exist back then? Were were you the first to say that? Where was that term uh adopted into neurology from medicine where it's more common, or what was it like in those early, in those early years when you were just trying to persuade your own chair and perhaps others around you that this was valuable?

SPEAKER_00 7:25

Well, it was changing uh what by the time I was an associate professor, and um our the University of Rochester uh developed three different uh promotion tracks. There was the traditional uh clinician scholar researcher, then there was the uh clinician scholar uh for education, and then also there was just a clinician. And so all three of them basically recognize expertise in those areas. But it was the clinician educator track that was coming out around that time. And uh, in fact, when the University of Rochester developed the promotion tracks, I was uh probably the first faculty member to get tenure on a clinician educator track. Uh, and that's because of my national stature and the international programs. It's not good enough just to be a good teacher and run good courses locally. You really have to have a national impact, and and that's what really helped me.

SPEAKER_02 8:22

It's helpful to hear you talk about how you analogized it to the other tracks and to sort of what they have in common and the fact that you know in academic medicine, there's kind of, as you were saying, certain ways to be successful, and sometimes that can be a little bit rigid, and to have to be able to persuade someone of a different impact or a different path uh certainly takes courage and perseverance, but as you have said, also takes results.

SPEAKER_00 8:53

Yeah, you know, one example was um I was very involved with the National Board of Medical Examiners writing questions, and uh I was on many committees, I was on the Medicine Committee, uh Clinical Physiology Committee, and on the medicine committee, uh I was a neurologist, but the majority of the other members were internists, and the chair of the committee actually ended up being the uh editor of the MAXAP syllabus, that's the medical knowledge self-assessment program for internists. And uh I was an outspoken member on the committee uh when I uh when we reviewed questions that I thought were picky, not just in neurology, but in other areas, I would speak up. And I initially thought the chair didn't like me, but I think he did like me. And then he asked me to become the editor of the neurology section of the Max Apps syllabus, and I was very young at that point. And uh and that was an outstanding experience because then I got involved with the American College of Physicians, and I would give the updated neurology uh talk every other year uh at the ACP annual meeting, alternating with Marty Samuels. And uh so, and then when I needed letters for promotion, I not only had letters from neurologists around the country, but from individuals in other specialties. And so the important thing is to get out of uh your comfort zone of just being involved with neurology and start getting involved in other specialties. And you could do this with uh being on the National Board of Medical Examiners and getting involved with other committees. So, you know, my advice to you is if you want to basically uh become very successful, you have to get involved in other specialties.

SPEAKER_02 10:38

Yeah, I was just gonna say this podcast is gonna be full of uh pearls, so I'm just gonna emphasize for our listeners, I think the key point here already is number one, get involved, and number two, speak up.

SPEAKER_00 10:51

Exactly.

SPEAKER_02 10:52

I couldn't help but notice, and you've mentioned um Dr. Samuels already, who was one of my mentors, but it seems to me, uh maybe uh you know, a small N, but that some really great educators come from Rochester. So yourself, um Dean Hundert, who uh was with you uh for some time and then came over to Harvard Medical School when uh he was the dean when I was a student, and of course, um our beloved Marty Samuels. Is there something in the water there?

SPEAKER_00 11:20

Rochester always uh uh had a focus on education, and uh uh so uh you know the biopsychosocial model of medicine basically was invented in Rochester with George Engel and John Romano. Uh George Engel was an internist. Uh John Romano was the chair of psychiatry, and the basis of that model is that uh patients don't become ill just because of biological problems, but because of psychological and social problems. And back in the 50s, there was a movement in medicine that wanted to divorce psychiatry from medicine thinking it was a pseudoscience. But uh George Engel and John Romano said no, it's really very important uh that we have to uh evaluate all of this in our patients. And if you go to any emergency room in the United States or even the world, half of the patients there are there because of psychosocial problems. So Rochester always had this environment for uh basically trying to uh do the best for patient care, looking at the whole patient. And education is really key with that. And uh we always had a good educational program, especially in neurology, and then when Ed Hunter came to Rochester, uh we devised the double helix curriculum that I was on the committee that did that, and this basically transformed the way uh our whole education curriculum in the medical school was organized, especially in the uh basic science years, integrating clinical and getting rid of the um uh courses that were run by departments and having interdepartmental courses. And even in the uh third year, the clerkship, uh the clerkships were redesigned. They maintained their emphasis on patient care, but they were integrated better. And so I think that uh uh you know Rochester really created this milieu. And then from the standpoint of developing neurologic educators, uh I was always supported, and uh uh I I must say that of our hundred or so faculty members in neurology in Rochester, 50 were my residents and 20 were my medical students. And so uh when you have a cohort of faculty members who trained in the program and in the medical school, they understand the importance of education. And then when it came time for me to basically step down from my leadership careers, uh, the roles, I had outstanding individuals that I trained that basically understood uh the need for having a very strong and organized educational program for medical students, which is part of the pipeline and also for our residents. So that's why I think we have a lot of educators, and I always ensured that they were involved nationally, um, and as you know, they've been very active in the American Academy of Neurology and all the education circles.

SPEAKER_02 14:21

Absolutely. No, it must be incredible to look out and see that kind of cascading pyramid effect. I mean, all of us as educators know that we touch the lives of our students, and I think for you, you really see that outcome. You know, it's it's the the ranks of the faculty are are filled, and and uh the impact of your trainees certainly continue. I wanted to get back to some of the things that you talked about. Um, I want to circle back to the way that you'd redesign the curriculum as well as to succession planning, which you mentioned. But one more quick question, just while we're on the topic of kind of the Rochester milieu. I noticed that you trained in internal medicine before you trained in neurology, and that's something that um Dr. Samuels did as well. And I think something we see much less of uh these days, and now that they're kind of um really a separated training process. And I'm curious uh what you know what your thoughts are about that. Is there something lost in our current training when we don't have that background? Um, what are the pros and cons of kind of training in two specialties versus just one?

SPEAKER_00 15:31

Well, back in the old days, um neurology did not have a match, and essentially most individuals did at least two years of medicine before they went into neurology. And when I started neurology, that was the first year of the match, and that's when uh essentially uh most uh neurology residents ended up just doing one year of internal medicine. But when I was applying, it was that transition period, and I really enjoyed my internal medicine, and I figured, well, if I'm doing two years, I might as well do three years and um become board certified. And the third year of medicine in Rochester was essentially all elective with all of the subspecialties, and I thought that was a great preparation for neurology, things like cardiology, nephrology, immunology, infectious diseases, and um I really enjoyed that. So for me, I think it gave me a better foundation when I started neurology. On the other hand, what I always say is that doing three years of medicine doesn't make you a better neurologist, it makes you a better internist. Uh but uh when I went through it, that's the way people did it. It's like child neurology. Child neurology used to be a fellowship after you did, you know, two years of pediatrics, and now, as you know, there's a movement to basically shorten that to one year of pediatrics uh for the same reason that adult neurology just has one year of internal medicine. So are the pluses and the minuses, I think the pluses it gives you more uh background in internal medicine, and certainly neurology now is an acute care specialty with a lot of patients with complications, neurologic complications of medical disease. But on the other hand, uh I don't think you need the three years of internal medicine like we did in the old days.

SPEAKER_02 17:21

Yeah, it's interesting to think about that perspective. I mean, even within neurology, we're always debating like, is the four years sufficient? Um well, three years neurology, one year intern, is it sufficient to cover everything you need, or is that our fellowships are becoming more required because you don't you can't fit in, you know, enough EMG time, you can't fit in enough EEG time. So it's an interesting experience to look back and look at how things are evolving within within kind of the scope of practice that we have now. So you were the clerkship director for an impressive 25 years and the preclinical course director for 22 years. You're also program director. These are just amazing tenures. Um looking at this, I can't help but be curious about what it was like to really be at the forefront of medical education as it shifted from like the 90s into the 2000s, the new technologies. What was it like to be in that leadership role for for such a long time period of time? And what was it like to kind of balance the successes of what you had built, but also continue to evolve?

SPEAKER_00 18:34

Well, I think the advantage for me was by running all three programs, I could integrate all of them with faculty and residents and get everyone involved in teaching all of it. I also had outstanding administrative support. I had a full-time uh program uh coordinator, a residency program coordinator. I had a part-time coordinator for the uh mind brain behavior course, and then I had a full-time uh secretary who was uh for the clerkship and also my secretary. So I essentially had two and a half administrators who were outstanding and very loyal. And I the way I work with administrators is I try to make life easy for them, really recognize their strengths and uh really promote them to be the best. And so that really helped out. And uh I started it, I didn't pick up all three programs at the same time. I started with the the old neuroscience course, which then was transformed to the mind-brain behavior course, and so I had that running and it was running well. And then the clerkship, uh, when I started, it was initially it was just an elective, a selective, and then it was in the fourth year, and there was very little uh organization to it, but then when we developed the double helix curriculum, we moved it into the third year, and I provided more structure uh for the clerkship. But my philosophy for the clerkship is that third-year medical students are like orphans. Why do I say that? What don't orphans want to be in the way? What do orphans want to be useful? And I got that line from the book Cider House Rules. And when you think about it, every four to six weeks the clerkship students are on a new service and they feel like orphans. And if the faculty and residents are switching willy-nilly at different times, they never feel integrated into the clerkship, and so they don't have responsibility. And also they get pulled out of clinical uh rot um responsibility for you know lectures, etc. So when I designed the clerkship, I made sure that our faculty and residents switch when the students switch. So each student is assigned to a team for two weeks uh with uh one, you know, a faculty and resident team, and then another two weeks on another team so they have continuity, and we don't pull them off their uh clinical activities. They do everything the residents do except for just a noon conference uh every day. So they really feel part of the team, they write notes that are uh uh can be used for billing, they present, uh, they come in early, they leave late, and they love the clerkship. It's the highest rated clerkship because uh they have a sense of uh achievement and responsibility, and when they complete, they really feel like they've learned something and contributed to patient care. And they're not orphans, uh, they're not in the way, and they're definitely very useful. So, you know, I and I kept it simple. It was it wasn't very complicated for me to organize it. And then the residency program, when I started, we only had four residents per year, and it was a uh an advanced program. And so I uh uh advanced it to a categorical program. We're up to eight residents per year now, we're going up to ten. And really created structure. In fact, when I was asked to become program director by Birch Griggs, my chair, I sat down and I wrote a five-page basically letter to him about my plans, my goals for the clerkship over the next five years. And I put it aside, and then I found it five years later and I accomplished everything. You know, you need to have a plan. And I had a plan and I knew what I wanted to fix. And so essentially that's the way I was able to do all of these things. I it was sequential. I had great secretarial support. I was organized and I had a good plan. And I uh, you know, I knew my faculty and the residents, and I was able to basically use them to teach the students and uh uh in a very organized fashion. And so that's why I think it really worked very well.

SPEAKER_02 22:58

Yeah, I have a colleague who likes to say, no matter how good your content, if it's not organized, the students aren't gonna like it. I wanted to dive a little deeper into some of the changes that you made. So you talked about you know observing the experience of the students and being a little bit lost and not integrated, and then you talked about changes and the plan that you had, this five-year plan that you accomplished. How did you go about making those decisions? It was it observation and what was kind of missing, was it looking to other models and successful programs elsewhere? Like how did you come up with that plan and what needed to change?

SPEAKER_00 23:39

Well, for the Mindbrain Behavior course, um the goal at that time was to make it a PBL curriculum. And I didn't know anything about problem-based learning, but I learned a lot about it. And but the other thing is there are some schools that basically have banned the word lecture. Lecture is a bad term and you can't use it. And lectures are a very effective way to present a lot of material in an organized fashion. And the problem with lectures is that lectures aren't bad, but bad lectures are bad, and most lectures are bad. And um, so in our mind brain behavior course, um it's uh five mornings a week, four hours a day, and we have two lectures every day, and then we have two hours of lab on Tuesday and Thursday. It's either anatomy, brain dissections, or now we have T uh TBL for neuropathology, and then um three session uh two-hour sessions of PBL every week, Monday, Wednesday, and Friday. And uh we have uh seven cases now, and each of the cases has a neurology and a psychiatry component. So I kept it very, very organized. And the students always knew what was going to happen, where they were going to be, and every morning uh I'd get up and give them the roadmap and signpost for exactly what's being covered in the course. And they really like that when they have a roadmap and it's organized. For the residency program, so um, you know, I was a resident and I knew basically what worked and what didn't work, and my plans were basically first to organize the interviews, uh, the second was to improve the evaluation of residents, the third was to create a resident handbook, the fourth was to basically codify the way the rotations are scheduled, um and then uh five was to get feedback from the residents and the faculty about the program. So those were some of the changes that I initially had in mind to make. And uh I organized them and it actually worked very, very well. So uh, you know, f the w one of the points that I always tell people, you know, to be successful in a career, you need focus, uh, communication skills, mentorship, and then a concept called managing luck, which is recognizing opportunities. But focus is very important. I knew what I wanted to do and I focused on it. And then communication skills, you have to be able to convince uh uh people to support you and to basically do what you want to do. And uh you do that by being an effective communicator verbally and in writing. Uh, you know, leadership is the art of getting other people to do what you want them to do because they think they want to do it. That's it. It's uh the art of getting other people to do what you want them to do because they think they want to do it, and you have to convince them that they want to do this, why it's going to work. And if they're on board, then you will be a very, very, very effective leader. Uh and you do that by really respecting the people you work with, uh, being organized, and getting uh allowing them to know why this is going to be the best thing. And then mentorship, you know, surround yourself by people that will help you. Um and also recognize and avoid narcissists, because there are a lot of narcissists out there in high places, and basically they could sabotage your career. So it's important to recognize them. And then the managing luck is basically recognizing opportunities. It's like if someone, you know, when I was asked to uh do you want to be uh the clerkship director, I said yes. Or uh would you like to be the program director? Yes, it was an opportunity. Uh the my international programs in Poland and Spain that all began with just a telephone call or or an email about are you interested in doing this? And I could have said, Oh, I'm too busy, I'm not ready for it right now. And the Poland thing basically began with starting an exchange program for two pediatricians from Krakow to a program now that over 25 years has impacted over a thousand individuals, medical students, residents, and faculty, both in Poland and in the United States. And um so that's uh basically recognizing an opportunity and making the most of it.

SPEAKER_02 28:10

Such good points there. I mean, I can't help but keep hearing the organization piece, just it sounds like you try to make the things that you can anticipate run smoothly, and then that kind of gives you the bandwidth to deal with things that you can't anticipate, which always happen as well. And I love the point about saying yes and catching an opportunity. I was wondering if you could speak a little bit more about that, the program that you've developed. I know some of it started through your work in the Fulbright, and I'm wondering how you came to that opportunity, how you came to consider the Fulbright and had this idea to set up the exchange.

SPEAKER_00 28:50

Yeah, well, that's an interesting story. So I'm Polish American and uh I grew up in uh Greenpoint, Brooklyn, a very Polish neighborhood, Polish school, Polish church, uh Polish community. And then when I came to Rochester, uh Rochester also has a Polish community. And so um I got involved with them, and then the way the program started was uh through the Sister Cities program. The Krakow and Rochester are sister cities, and the Sister City program was started by President Eisenhower during the Cold War as a people-to-people connection. So um a pediatrician in Krakow sent a letter to our chair of pediatrics in Rochester through the Sister City Connection, uh, trying to set up an exchange program for a few of his faculty. So that letter ended up going to uh Bob Joint, who was our dean and he was my former chair, and he calls me up. He said, Ralph, you want to go to Poland to check this out? I said, sure. So I went with a colleague for a week and we uh met people, we set up the program and we have brought over two pediatricians. Following year I called up Bob Joint and says, I want to go back to Poland to see how things are going. He said, Okay. And I met the chair of neurology in Krakow and he invited me to come teach. And so I decided I'm going to apply for a sabbatical. And then a Rochester colleague told me about the Fulbright program. I didn't know anything about that, and so I looked into it and I applied, and I got a Fulbright. So I combined a Fulbright with uh a sabbatical, and in 1992 I went to Krakow for six months and I taught neurology in English to four groups of students, and it was the best professional experience in my life. I didn't know exactly what I was going to do, but uh it was so exciting. I even joined a choir, the Jagalonian University choir, and we sang around Krakow in southern Poland, and it was just a great experience. Several years later, um, the Jagalonian University, uh, which is where I taught and incidentally is 660 years old. Their famous alumni include Copernicus and Pope John Paul, so it's very distinguished. They started an English language track in their medical school, and the chair of neurology invited me to come and teach the clerkship. The first year there were just six students, so I could do it myself, but as the number increased, I came up with this plan to bring faculty from Rochester, residents. Uh, we started a student exchange, uh, bringing students from Krakow to Rochester, and then I started to bring Rochester students to Krakow to teach as well. And we had faculty workshops and we had faculty exchanges, and over the course of 25 years, there have been over a thousand people impacted by the program. And uh so right now uh for many years I would go for one month and bring all my chief residents and uh about 10 Raja students, and we taught uh clerkship in English to about 25 uh medical students in Krakow. And uh so I guess one of the questions is who funds this? Well, the English language track in Krakow is a moneymaker for the medical school because they now, in addition to Americans and Canadians, they also have Norwegians uh who study medicine in Krakow because Norway only has four medical schools, and it's cheaper for them to contract with Jagalonian than to build a new medical school. So uh Jagalonian makes about three million dollars a year on the uh exchange program, and with Rochester going there and the big impact we had, uh this adds stature to the program. And also when we bring over the Polish students uh to Rochester for the four students, we give them free tuition and we uh give uh pay for housing and giving uh a little uh uh a stipend uh basically. So uh it's it's a win-win situation basically. And so that's basically how uh the program is funded. And it's it's important to make sure you have a funding stream to keep these programs going.

SPEAKER_02 33:08

Yeah, the level of sustainability is really impressive, uh, just in terms of, as you said, financially making it kind of solvent over those years. I think it's also an incredible opportunity to hear from you what it's like to iteratively grow a program over that time. I mean, so many of the people I speak with are maybe a few years into a program, you know, two years into a program, five, maybe even ten. And I think when we look back, it's incredible how much you can accomplish when you have time, but it's it's rare to have that length of time to actually do this kind of work. And so I'm curious if you could share with our listeners, like, what was it like to change iteratively? Like, I don't know if you remember what some of the big milestones were, but like what kind of change would happen from year to year? I can see how the impact is now, you know, exponential because even a small change year to year can have a big impact. And I'm curious if you could walk us through some of the changes to give a sense of like what it was that you were adding on year to year as it grew.

SPEAKER_00 34:14

Well, I think the most important thing is um uh working with people and coming in, not as an American, if I'm an American, I know everything, and I'm gonna tell you how to do things, but rather have being very humble. And it's uh I'm going to learn as much from you as hopefully you'll be able to learn from us. And that's very important. And to make yourself indispensable, uh basically deliver a great program, be very organized, always thank people, but also be tough when there are things that you have to negotiate and get, uh, but you have to treat people well. Um shortly after the program began, uh one of their residents, neurology residents, uh, came to Rochester for a couple of months just to see how we do things here. And to make a long story short, this individual came several times later, learned molecular genetics, and she's now the chair of neurology in Krakow, and uh uh one of the most successful neurologists in Poland. In fact, uh with the prior uh administration in Poland, she was the chief neurologist for Poland. And she learned molecular genetics and learned how to be a researcher and learned how to be a chair with her visits to Rochester. So this was one of the ways that you know we cemented things. We really helped them a lot. And then there was a pro bono project from the EU where ten of their junior faculty came to Rochester for one month each in different specialties to basically learn how we teach and and et cetera. So uh we basically provided a lot for them. And then for me, uh I ran an outstanding course and always got the highest ratings from the students. The students really loved it, and uh and then I was always very respectful of all of the faculty and the administrators, and uh and so that's why it became such a successful program. And then a lot of their medical students who came uh to the US for rotations, um actually 15 of them ended up having uh doing residencies at the University of Rochester, and I had five who did residencies in Rochester in neurology, and um uh uh several of them ended up being faculty members. So it was like a win-win situation. But I I think the key thing is um I I was very involved with the program. I'm still very involved. I'm there all the time, I mentor everybody, I make sure it runs very well, I set very high standards, uh, work well with the uh faculty there and the administration as well as here. In fact, our dean in Rochester a few years ago said that the exchange program with Krakow is the most successful international program the University of Rochester has. And several years ago, all of our education, all of our deans, actually, senior deans, went to Poland for a week and we had a conference there, which I thought was incredible. I got all of these deans to go there, and they had a wonderful time. It's a great city, and uh uh you know you want to basically make the program uh I I I I guess I could say sexy. In other words, it's it's a great program, and everyone at the University of Rochester, the medical school, knows about the program. They enjoy working with the Polish students, and uh a lot of them have been over in Poland as well. So I I knew what I wanted to do, and I wanted to make it successful, and I did that by treating people well and um exposing a lot of people to the joys of going to Krakow and teaching at the Agalomian University.

SPEAKER_02 38:02

Yeah, it sounds to me like what you're emphasizing is really deep invested relationships. It was about they knew that you were there for the long run, they knew that you cared deeply, and I think out of that trust, these opportunities came up, and as you said, became a win-win, became something that they were proud of and something that Rochester was proud of. But that level of investment is that deep investment, I think it doesn't always happen these days. Sometimes these interactions are you know transactional or kind of superficial, and I do love this idea that like when you plant really deep roots, um, that the tree that grows will be very strong.

SPEAKER_00 38:44

Yeah, and I was always supported in Rochester, um, especially by Bob Joint, Birch Griggs, Bob Holloway. And it's not like, well, why are you leaving the University of Rochester? You have to see more patients and bring more money in. I convinced them that this program will make the University of Rochester Neurology Residency Program and the department more successful. And I did that by bringing over a lot of our faculty uh to Poland. And uh so, you know, I made everyone, I convinced them that this is a great thing. And and the other point I want to make is um, you know, the the Sawyer uh principle from Tom Sawyer that he got people to pay him to whitewash the fence, uh, the adventures of Tom Sawyer. So that's what I do. I get all my residents to do all the work. They do all the teaching when I'm in Krakow, and they love it. They get paid also. I mean, all their expenses are paid and they get a small teaching stipend. But I don't have to do that. I just I give a few lectures and I organize everything, but essentially my residents do all the work.

SPEAKER_02 39:48

So that's the key to sustainability is oversight. Yeah. So you've told me before when we've chatted, and our listeners won't be surprised uh hearing you share what you've done so far. But you always said that you aimed with your courses, your clerkship, the program to simply be the best. You know, the the simple goal, be the best. You set high standards, high expectations for yourself, and you met and exceeded them and through your own role modeling and through the commitments that you made. So I'm curious if you could dive a little bit more into this. Like, how do you set these standards and goals for the programs you're running, and how do you approach iterative improvement?

SPEAKER_00 40:32

Well, um I focus, well, first of all, I always I guess it's part of my background. It's always trying to be the best person you can be, uh, not for yourself, but for everybody. And I'm the happiest when I make other people happy. It's it's part of my Polish Catholic upbringing, but it's just sort of what motivates me. But um, you know, so I always set the bar high, and I think that's really uh very important uh to do that. Uh how to motivate people, uh basically I I wanted to make sure that everyone achieved their potential. And what I was going to say is I focused on outcomes and not process. So um basically, if you say I run a good course because uh you know it's organized well, no one really cares about that. But if you say I run a good course because look at the outcomes, look at the feedback from the students, look at the number of students who go into neurology, look at the scores on the uh the USMLE. And um every year for 20 years or so, I would have a grand browns in our department updated in education, where I collected all the data that I could from the residency program, the clerkship, and from the uh neuroscience course, and uh had graphs showing all of the uh objective data. And good data is nice, but if you fail in certain areas, everyone wants to do well. And if you show data that's not the best, people will want to be better. So focusing on the outcomes. And I also shared that that presentation with our deans, and I also shared it from with colleagues around the country as uh impetus for them to start doing this in their departments. So I think it's very important to collect the data, and it's uh essentially with data you could really make things better. So uh by being, you know, wanting to be the best, it's not just saying you want to be the best, but it's basically proving to people with outcomes that uh you're really very good because everyone wants to be part of a winning team.

SPEAKER_02 42:53

Yeah, I'm glad that you mentioned that grand rounds. I had heard you speak about it before, and it was eye-opening this idea that we can set standards and we can gather data and we can improve it like anything else. And I think that that is important in education. I think it's important to speak the language that is being speak spoken about, you know, in the scientific realm or in the clinical realm, and to say the same that we have goals here, we have objectives, we have goal uh results, and you know, how are we doing uh that can really move the needle, I think, on the importance of this and also to demonstrate the impact that you're having when you make changes. I wanted to come back to this idea of successful succession planning. Of course, after you run something for 20, 25, 30 years, it's important to hand it off well. And you've done that with so many of your programs. So I'm curious how you pass things off the neuroscience.

SPEAKER_01 43:51

Succession planning is really very important. Did you have a you know, did I stay to implement in these programs here?

SPEAKER_00 44:00

I really enjoyed it. I was doing a good job and people liked it. But as I was getting older, I just figured it's time now to step down. And uh so um I identified individuals early on uh to basically uh take over. So for the mind brain behavior course, Dr. Christopher Taroli, who was one of my residents and who definitely expressed an interest in teaching, was someone that identified. And uh so I asked him to become co-director of the course uh a couple of years before I decided to step down. And then um I stepped down and basically got out of his way, and I still give lectures and help out any way I can, but he really has done a great job, and one of the uh best things he did was to uh create a uh team-based learning for neuropathology, uh which was a result of some faculty changes that we had in neuropathology here, and he created uh all of these modules, 10 hours of these modules, and did a really great job. So he really added a lot more to the course, and the course remains excellent. Uh for the clerkship, um, Rob Stone uh mentioned that he was very interested in taking that over, and so he became uh the co-director of the neurology clerkship, and then he eventually took it over. Uh he made some slight changes. There's always changes that have to be made, uh, but he's done a great job. And now um he's passing the torch to Lauren Heminger, um, who was one of our residents, and uh she just became faculty in neuro oncology. Uh she was also one of our medical students, and she is outstanding, and she's doing great things with the uh clerkship. For the residency program, Dr. Colleen Tomsick became the program director. She was at um case uh working with um David uh Preston, uh senior moment there. So anyway, she was his associate program director, and then she came to Rochester and uh uh became my associate program director for a number of years, and she always wanted to be a program director, and so it was obvious that she would take the program over, and she's done a really great job. I would have stepped down earlier uh from the residency program, but COVID came, and right at that time I just decided it would be best for me to continue for a year or two more uh to get us through the COVID experience, and then I stepped down and she took it over. So I basically planned the succession planning, and I think it's very, very important to do this. And what was great is right when I gave up the residency program in December, that January, I went to Poland for my second Fulbright, so I got out of her her hair. And uh, you know, you gotta get out of the way. And I was in Poland for six months, and uh I was always available, would speak with her every couple of weeks on the phone. But uh, and now I just enjoy teaching, running morning report, uh, being on service, seeing patients, uh teaching students, uh, but really no administration. I do no administration, and I also got off of all of my national committees, and uh which is uh really a a great relief. I really enjoyed what I did, but you know, you want to leave before they start saying, when is that old geezer going to retire? And so you want to leave uh on a high note, and I think I did leave on a high note, and uh it's I really feel so proud of the programs that I established and all of the people that I mentored. Uh, and I think the succession planning was one of the most important things that I did.

SPEAKER_02 48:04

I always love to ask the people on the podcast what they're most important about. Oh, the people I venture.

SPEAKER_01 48:09

And uh I've heard so much already what you're sharing, but I I'm gonna ask anyway. I'm the happiest one of the other people.

SPEAKER_02 48:32

So shifting gears just a little bit, uh, but I can't help but ask not ask this. Um, and you mentioned at the early beginning that you're uh have been known to be outspoken, and I've always loved uh having you on a panel. You know, you always know something something fun is gonna come out when when you're in the room. So, Ralph, you coined the term, it's now almost infamous, of neurophobia. There was a paper in uh the late 1990s um where you, I think a little bit tongue-in-cheek, and I don't know if people realize that, I don't know if people have read the original, uh, coined this term and and offered some origins that it might be genetic or at least passed along in family.

SPEAKER_00 49:12

I was on the undergraduate education mitigation and treatment share at that point.

SPEAKER_02 49:17

What's the origin story in the word article?

SPEAKER_00 49:19

Discussing uh the pipeline, the reason that students don't go into neurology, and we discussed this the fear of neuroscience. And so someone says neuroscience phobia, and I just says, well, let's just call it neurophobia. And then uh there was an AEN meeting coming up, and I gave a talk at one of the education sessions, I think it was the uh Amy Baker education uh colloquium, and I just thought of it as a disease, you know, with signs and symptoms and an epidemiology, and uh uh and so I it was tongue-in-cheek, and and if you read the initial uh paper, uh that that's basically it was. It was a disease of medical students uh that they have a fear of neurology. And if their parents uh are physicians and have neurophobia, they will probably have neurophobia. And uh, you know, it peaks in the neuroscience course and also during the neurology clerkship. And I said the key problems with it is the lack of integration of the basic science with the clinical. That the and at that time all the neuroscience courses were taught by PhDs. And, you know, they're very good teachers, but they didn't understand the importance, the clinical importance. And then when the students got on the clerkship, um, you know, they saw the neurologists as these mystical people who would basically figure things out and they had no idea how they got there. And so I said that was the problem, is the lack of integration between the basic and the clinical science. And so um that was the talk. It was very tongue-in-cheek, well received, and Bob Joint, who was the editor of Archives of Neurology, then told me to write it up. So I had it was interesting, I was in Poland and I had my slides, and I had my dictaphone, and I just showed the slides and I dictated the whole thing, and then it was transcribed, and then I just tweaked it a little bit, and he published it as a letter in the archives. And it was a sleeper, and you know, nothing much happened over the years, and now it's been cited over 500 times, over 500 times, and you know, in fact, I should put it on my tombstone, he defined neurophobia because and it's so true. I had absolutely no evidence at all, I had no, you know, uh research on it, it was just my thoughts. And you know, I said the incidence is about 50%, and now they study all these things, and it is about 50%. I think they could do all of these studies about it and come with data, and still what I said without any data was 100% accurate. It was just my idea. And you know, that's another point you made about being outspoken. You've heard me speak at meetings, and uh I'll never forget um when the milestones were being rolled out, uh, they had the ACGME um people there, they were talking about these, they wanted to have uh portfolios and narrative stuffs and journals, and that was really annoying the program directors. So I got up and I said, the problem with this is if you treat residents like children, they will act like children, and if you treat them like adults, they'll act like adults. And I got applause. And and and the you know, the thing was that was uh that was a bold statement to make in the big audience with all the program directors and all the ACGME people, but I felt strongly about that, and so did all the program directors, and I felt I had the clout to be able to say that. And uh as a result, you know, the milestones have been watered down since then. So my advice is if you feel strongly about something, don't be afraid to get up and say it. Uh and you know, people may disagree with you, but I think it's important for you to basically make known uh, you know, the thoughts that you have.

SPEAKER_02 53:14

Well, thanks for that reminder, Ralph. I think we uh all feel we need maybe 30 years of experience under a belt before we can say that, but but we're still gonna try. So as we as we kind of wrap up, I know we've been talking a lot, kind of looking backwards, looking back on your career, what you've done, what you're proud of, what you've accomplished, which is just so incredible. And now I just want to kind of look forward. Um, you know, as you look to the next 30 years or 40 years, 50 years, what do clinician educators in neurology needs? Basically, how can we advance neurologic education? What does this next generation need? What's our mission? What's our vision? What support do we need?

SPEAKER_00 53:54

You know, educators with PhDs who are not clinicians and who have notions. Every five years, there's a new educational notion. And just because it comes out doesn't mean it's the right thing. The basics of being a good teacher is uh, you know, knowing the subject, liking the subject, liking your students, and knowing your students. And I think that's really the essence of being a good teacher. And uh and you know, be a good communicator, have focus, uh, work well with your educators on the team in the medical school, uh, recognize people, uh, thank people. It's very important to thank everyone you work with, work well with your administrative staff, and really enjoy what you do. People love working with happy individuals who are optimistic about the future, and they don't like to listen to complainers who just whine about why things can't be one way or the other. I never whined about things. I basically, if I didn't like something, I try to fix it, but I try to get people on board uh to support what I was gonna do. So my advice for the future is be optimistic, work hard, be organized. Um and the other things are um, you know, being be able to laugh at yourself. And if you make a mistake, um, you know, don't wallow in self-pity, take responsibility for it, don't blame others. Stand up, learn from it, and move on. And it's very important to do that. Um and that's what I did. I mean, I made mistakes and um and occasionally I hurt some people, and if I did, I apologized right away and try to learn from that. Uh but you know, I was very sincere in why I wanted to do the right thing. So I think that that's the important thing, you know, be a good uh person uh and uh and work with individuals and you could really accomplish a lot.

SPEAKER_02 56:02

Well, this has been a masterclass, not just being a clinician educator, but I think in really being a leader, what it takes to really have impact, and it is, as you said, getting others on board and getting them to do what you you think they need to do. I'm just gonna keep on what they want to do it. You know, I'm 73 next to help us.

SPEAKER_01 56:20

We have to keep working on teaching for you.

SPEAKER_00 56:23

When I go to you for future two weeks every year, and I teach there with the chief resident at the University of Navarra in Pamplona. Uh and in Rochester, uh it's very important. You know, I'll be here for six months a year, and I'll be seeing patients and I'll be teaching, running morning report, and just trying to help out as much as I can. Just be a support uh to all of you know the junior educators and the residents, etc. So that's all I'm gonna do.

SPEAKER_02 56:50

Thanks so much, Ralph. Any final words, anything I didn't ask that you want to mention?

SPEAKER_00 56:55

No, thank you. I really enjoyed this interview, and you know, it's it's really an honor to be uh asked to talk about my career. I mean, I'm I I feel a little embarrassed about it, uh, but uh but it's really, you know, everyone uh with whom I worked and everyone has just really shaped me, and I have a depth uh incredible gratitude to everyone that I've worked with.

SPEAKER_02 57:19

Well, just know that your spheres of influence are large. There are the direct mentors and mentees that you've mentored, there's the people you've advised, but there's also the role model um that you are for so many more of us. So thank you for everything you've done and uh for speaking out loud, for getting involved, and also for uh your you know tips on really being successful in this career. Thanks for charting the path. Neuropraxis, the neurology educators podcast, was created and produced by Gelena Gaitman. It is not recorded as an official podcast of any institution or organization. The views and opinions are those of the individual speakers themselves. Music from Pixibade. Cover art by Carolyn Folney. Editing by Valeria Rowden. Want more content like this? Be sure to subscribe to the Neuropractices Podcast wherever you get your podcasts. Have questions, comments, or suggestions for other podcast episodes? Contact us at neuropraxispodcast at gmail.com. Tell your friends and spread the word. Thanks for joining us.