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The Baylor College of Medicine Resonance Podcast is a student-run podcast aimed at showcasing the science at Baylor through the eyes of young professionals. Each episode is written and recorded by students who have a passion for research and the medical community. Guests on the show include both clinical and basic science research faculty who are experts in their fields. We hope that whoever listens in gains new insight into the exciting world of biomedical research.
Aruni Areti: Hi and thanks for listening to the Resonance podcast, a podcast run by medical and graduate students here at Baylor College of Medicine, where we get the amazing opportunity to interview clinicians, faculty and researchers about their work in an effort to promote health education and equity. My name is Aruni Areti, and I'm a second-year medical student here at Baylor College of Medicine, and here I'm with-
Sydney Larsen: I'm Sydney Larsen. I'm a second-year medical student here at Baylor College of Medicine.
Sydney Larsen: Today we're joined by Dr. Atul Maheshwari, an Associate Professor in the Department of Neurology and Neuroscience, and the new Assistant Dean of Curriculum at Baylor College of Medicine. He began his medical education here at Baylor and then went on to do his residency in Neurology at Massachusetts General and Brigham and Women's Hospital in Boston, and then returned to Houston to complete a fellowship in Clinical Neurophysiology with a focus on epilepsy. He now practices and teaches at Baylor College of Medicine, where he also leads a research lab that focuses on epilepsy and ADHD. On top of that, Dr Maheshwari played a key role in the recent transformation of BCM’s medical school curriculum, helping to redesign the Behavioral and Neurological Sciences unit for preclinical students. In this episode, we'll hear about Dr. Maheshwari’s journey to medicine, the science behind learning, and how we can use these principles to inform how we study and retain long-term information.
Aruni Areti: I've been really excited for this, and I think this was a super, super great conversation.
Sydney Larsen: Let’s get to it.
Sydney Larsen: Okay, now we're back with Dr Maheshwari, how are you doing today?
Dr. Maheshwari: I'm doing great. Thank you.
Sydney Larsen: Happy to have you with us today. I guess we'll get started. Let's talk about your path to medicine. What drew you to medicine and then to specialize in neurology?
Dr. Maheshwari: Initially, it was just the default pathway. My dad's a physician. He's an endocrinologist in private practice in Beaumont, Texas, and so it was kind of the natural thing. I idolized my dad. I still do. He’s a lifelong mentor, and I saw what kind of impact he made in the community and on his patients. Got to see him in action once in a while, and that's probably where it all started. And then this is where I feel a little guilty because I was, I would say, selfish. I think I had a crisis in high school where I really went down this pathway of thinking that everything anyone does is selfish. And then I think where I came to our realization was through watching my dad, and I could tell that he got enjoyment out of what he did, and bonus, he got to help other people as well. And so that's when it hit me that I could explore the things that I found exciting and interesting, and at the same time help other people through the things that I found interesting and exciting. And then it was a win, win. And then I was okay with being selfish. I came to that, I guess, resolution of that conflict. And then ultimately, I said, okay, this works for me. In high school, college, I got really interested in the brain, how the mind worked, again, selfishly, how my own brain worked. How could I improve that? I was really focused on my own memory. I thought, well, you know, what is the best way I could improve my own memory and learning? And then extrapolated that when I came to medical school, and thought, okay, how can I help others with problems that are neurological as well? And so that was the basic pathway to medicine and neurology.
Sydney Larsen: You trained in Boston, but then you ended up coming back to Houston. What brought you back here? And how did that shape your trajectory and your career?
Dr. Maheshwari: I guess it was multifactorial, but probably it started. I was in my third year of neurology residency, third out of four years. And there was a grand round speaker that was coming from Baylor College of Medicine, Dr. Jeffrey Noebels, and he was a giant. He is a giant in the field of neurology and epilepsy. And as a resident, you get the opportunity to have dinner with the Grand Rounds speaker the night before. And I signed up. Absolutely. I said, Yeah, this is coming from my hometown, I'd love to meet with him. And it was then that he shared that there was a postdoctoral research fellowship available, it was open, and that if I was interested, I should reach out. And I was sold. Between that conversation and then his grand rounds talk, the opportunity to look at a basic science level, a molecular level, of what's going on in the brain, in epilepsy, that opportunity, I thought, was just amazing. And so that was probably 50% of the decision, and the other 50% was family. My whole family's here in the greater Houston area. My wife's family's here. We were pregnant in our PGY-4 year, the last year residency, and we knew that if we were going to be raising a family, it'd be great to have family around. And so all of that worked together really well. It was a no brainer to come back to Houston. There was a lot of excitement about coming home and giving back to Baylor. So, I did my fellowship in epilepsy. It was a two-year fellowship, one year of research, and then one year of learning how to take care of patients with epilepsy and reading EEGs. And then I joined the faculty in 2012.
Sydney Larsen: At what point did you first become interested in epilepsy? Was it before that talk, or did that talk kind of start everything?
Dr. Maheshwari: Oh wow, what a great question. Yeah, so I'll tell you, when I was interviewing for residency, I remember very vividly telling all of those who interviewed me that I wanted to do Behavioral Neurology as a fellowship. As I mentioned, I was very interested in how cognition and memory worked, and I thought I wanted to go in a field that focused on that. And to me, I was only really very familiar with behavioral neurology as an opportunity. The residency program director at that time was a behavioral neurologist, and I had gotten a lot of exposure through that. And it wasn't until later that I realized that that mostly a career in behavioral neurology was mostly a focus on dementia, which is an important field, and it's growing in terms of its patient base, as well as the opportunities that we have to treat patients with dementia. However, at the time, when I was training, I was a little bit turned off by the opportunities for treatment. I again, still had a lot of respect for those who were helping patients and their families with closure, with diagnoses and with symptomatic treatment of their disease processes, but I was really looking for something that I could have more of an impact when it came to treatment. And that's when I learned a lot about epilepsy, and that wasn't until residency. And in residency, early on, you get a lot of exposure to patients with seizures and refractory seizures, and I found early on that number one, we have a lot of great medications and it's not straightforward. There are some medications that work better than others for certain patients with certain comorbidities, for example. So that was a fun kind of puzzle that I found myself trying to solve with each patient that I had with epilepsy. And the number two, there were a lot of patients, about a third of our patients, who don't respond to medications. And so, we have to think outside the box. Think about is this even epilepsy, characterize their seizures better, and then, if it is pharmaco-resistant epilepsy, drug-resistant epilepsy, what other options are there? And it was during residency that we were really starting to get all this news about neuromodulation, response of neurostimulation, deep brain stimulation, as opportunities to help treat those patients who had drug resistant epilepsy.
Sydney Larsen: What is most exciting to you about the research that you're doing today?
Dr. Maheshwari: I think I have shifted over quite a bit from the research that is in the lab and based on mouse models to more education-related research, but I think there is a theme that kind of goes throughout and so I think from the mouse side, the part that's most interesting is we were looking at, what happens with the EEG, what happens with brain waves, whenever mice are making decisions that are clear that it's due to paying attention, versus they're clearly distracted. And one of the cool things that we found was that there's this rhythm called the alpha rhythm, and whenever it's too high or whenever it's too low, the mice have difficulty paying attention, but whenever it's right in that sweet spot, in this kind of middle ground area, they're much more likely to get the correct response in an intention task. And so, I think I'm finding that to be applicable to a lot of the research in the field of education that either you know, having too much or too little oftentimes is not as helpful as being right in the middle. I'll give the example of there's something that's known as the Yerkes-Dodson law. It's this idea that there's this inverted U curve. It's most clearly been studied in terms of arousal. You can imagine, right? Like, if you're in a classroom and you're feeling sleepy, you're not going to be learning very much. But if you're on edge, you drink five cups of coffee, your mind is going to be so easily distracted, and it's going to be hard to pay attention. You're hyper aroused, and there's that kind of middle ground where you're in the zone and you're able to learn the best. And so, I think the more and more that I've shifted over from basic science research to more education research, I'm seeing a lot of parallels between what we're finding.
Sydney Larsen: For our listeners, Dr. Maheshwari is a big name on campus, especially for the MS1s. I mean, maybe for everyone, at least he was a big name on campus for Aruni and I as MS1s. But how did you first get involved with medical student education?
Dr. Maheshwari: You are very kind. Thank you. I did not come into it intentionally. I think it kind of, I should say, grew on me. And I think part of what I realized was that there was a really great potential to have an impact in the world of medical education that I didn't see when I first started. So, when I first started as a as faculty here, I really was focusing on the clinician scientist pathway. I was really excited about the potential impact I could make in the world of research, figuring out new and exciting things in the world of epilepsy. And then I think slowly, I got more and more involved with the medical student side of things. Part of it was nostalgia, because I was a medical student here, and I wanted to give back, and that's probably why my first major involvement was really more on the Student Affairs side, rather than the curriculum side. For nine years, I was a Learning Community Advisor, and I identified so much with what the students were going through as a recalling of what I had gone through as a medical student as well. And I really relished the opportunity to help students go through that process and say, hey, I've been there. I understand. And you know, one of the recurring themes from the medical students as I was walking them through day one of medical school to graduation was the challenges with learning in the clinical environment. That on their core clerkships, in particular, how students felt they were doing everything right, quote, unquote, right, that they were doing everything that was asked, and they were learning a lot. But then it didn't translate necessarily to what they ended up getting as their final grade. And then as I kind of continued to progress as a faculty member, I got more and more opportunities to be involved with the curriculum. Dr Goodman, Dr. Clay Goodman, who's now retired, I owe a lot to him as a mentor to have me become involved with the nervous system course now the Behavioral Neurologic Sciences course, and eventually took that over as co-course director, and then with curriculum renewal continued on as co-course director for the Behavioral and Neurologic Sciences course, which you guys got to take last year. But it was really probably in 2021, when I joined the curriculum renewal work group, that I started to realize where I could make even more impact, and that was in the clinical curriculum, the clinical sciences curriculum, and so through the curriculum renewal process, one of the big things that was happening around the same time was the decision to go pass/fail for the core clerkships. And this was not universally accepted as a given. There was a lot of concern that students would not be able to differentiate themselves if they didn't have this kind of tiered grading system. And then ultimately, working with our group of curriculum deans, who are all amazing and really clearly have the students best interests at heart, we were able to kind of get a consensus from all of the stakeholders, that includes students, the Office of Student Affairs, our GME representatives, our residency program directors. I wouldn't say that it was a universally held belief that this is going to be a positive thing, but there was enough momentum to address the concern of the most fundamental goal of the clinical rotations was to learn. So, all of that's to say that I'm glad I had an opportunity to have a hand in that transition. There were a lot of people that were working on that for a much longer time before I joined, but that was around the same time that we were able to also, under leadership of Dr Christner and all the other curriculum deans, create this really robust clinical curriculum that you guys are about to about to embark on, which I think the best way to put it, is it took what clinical curriculum I remember as a medical student, which was amazing. I think I learned so much, and it supercharges it, and it takes all the best parts of it, and it says, how can we make this the infrastructure for all students, so that everyone gets the best parts of curriculum, rather than leaving it to some degree to chance.
Sydney Larsen: I’m very grateful, personally to be a part of that pass/fail clinical curriculum. I can't speak to how it makes me feel, because Aruni and I start in about a month, but I guess it takes a lot of the pressure off of coming into this new environment with new roles as a medical student.
Aruni Areti: Yeah, I was also just going to add that what I'm most excited about, you know, is also not worrying about my grades, but actually just focusing on learning. And something I'm even more excited for is building relationships with my attendings, the residents, the peers, and the patients as well. And I think over the past year, I've seen that focus on collaboration and really building a community. And I'm really looking forward to that in my clinical rotations as well. That kind of leads me into this next question--something that also really surprised me about starting medical school is the didactic time set aside to teaching us learning skills. I remember this when I first started, you gave us one of these sessions that focused on the neuroscience of learning and how we could be all effective with our limited time and energy. So, in that case, at the brain level, could you take the time to explain what happens when we learn something new? Can you walk us through some of those key systems involved, perhaps?
Dr. Maheshwari: Sure, sure, absolutely. Thank you. The fact that you remember that we talked about that last year is a testament to us doing something right, that you remember it. The goal was to make it clear that there was a rationale, there was a reason behind the way our curriculum is set up. We did spend a lot of time looking into the evidence behind what are the most effective strategies for teaching. And I'll first just mention that I think a thing that kind of clicked for me over the last several years is something I kind of always knew in the back of my head, but it became more clear, I'd say, over the last five years for me, and that is the difference between teaching, which is what the faculty are supposed to be doing, and learning, which is what the students are supposed to be doing. I would say, as a medical student, when I was in your shoes, I thought the process of education was 90% teaching and 10% learning. And so, I was so excited I was coming to Baylor College of Medicine, where they had all these great teachers, because I thought that was where the money was, in the teachers, not in me. I was only going to learn if I had really great teachers. Now I've kind of flipped, and I think it's much more 90% on the learner and 10% on the teacher, in the sense that, the way that a teacher can maximize the ability for a student to get an educational experience is to make sure that the student is doing a lot of the work of learning. This idea, I think, that is antiquated, is this idea that we are sponges, that if I tell you everything that you need to know, then surely you've learned it. I think it's clear. We've all been in those situations where we heard an awesome lecture and we're like, ah, that was so great, and then the next days, I mean, so what was what was it about? Like, I don't remember it was hard to come out, or you remember it for a little while, but then it eventually goes away, unless you've done your due diligence in trying to quiz yourself and recall that information. And so that's really the fundamental, I think evidence-based truism when it comes to learning, and that is that passive learning, while it feels like you're learning, is not as effective for long term retention. And the basic sciences behind that is fascinating. I can't tell you that I'm a super expert in this. This isn't any area that I've done research in, or active research and mouse models, or any particular studies, but in the process of curriculum renewal, we definitely did look at that and try to understand that. And in preparation for your Behavioral Neurologic Sciences course, I was tasked with trying to understand, on a very basic, fundamental level, what's going on there. So, we can go through that briefly. So, the basic idea is that there are collections of neurons in the brain that represent any given idea. Okay, let's say the idea is that excitatory neurons make glutamate as their primary neurotransmitter. Okay, that is a fact that is helpful for learning neuroscience, and I'm trying to teach that to you, there are a collection of neurons in your brain that, when firing together, represent that fact, and we call that collection of neurons an engram, okay? And when I tell it to you the first time, and you're hearing it for the first time, and you're thinking about it that, okay, glutamatergic neurons are excitatory, then it's there. The connections are there. The neurons are connected to each other, and they're firing, and they've gone into the encoding phase of memory formation. The problem is that no protein synthesis has happened at that time. It's just that the connections are there, and receptors may have been shifted around in order to make that those synapses a little bit more cohesive, but they're not consolidated memories yet. So, they're there, and they're there for a while, but they're at risk of disintegrating and not consolidating and becoming, you're at risk of becoming amnestic for that fact, unless you move into active learning, the consolidation phase of memory formation. And what's clear is that the best way to do that is to recall that memory again, is to ask yourself, what type of neuron makes glutamate and then come up with the answer of the glutamatergic excitatory neurons. Right? The answer was excitatory neurons, and being able to walk through that and activate that, that engram again, that uses what we call theta oscillations. That is what then moves you into that consolidation phase, that's where protein synthesis happens, that's late, long-term potentiation. All of these processes then help to make that that fact a little bit more solidified in your brain, and the more you do it, the longer you'll be able to retain that memory. So that's the basic idea behind it. Any questions about that?
Aruni Areti: I guess my first question is related to understanding how stress and emotion kind of affects this process you were talking about. And that kind of stems from the fact that we understand med school is very stressful. There's a lot of very new things going around you and are expected of you.
Dr. Maheshwari: That harkens back to what I was saying earlier about the Yerkes-Dodson law. And I think in general, and this is a generality, so there's lots of exceptions to this, but in general, you want to be in the middle of that curve. So, you want to have a little bit of stress. You want to be motivated a little bit by that stress of, oh, I think I need to know this. I better pay attention. But you don't have too much stress, because then you're going to get distracted. You're not going to be able to focus. You're not going to be able to be in the mindset where you can make those theta oscillations that will then help you move into that consolidation phase. And so, I think that's really important, and that is one of the driving factors behind whenever I'm giving a large group interactive session, I do start out by trying to make sure that the tone is set, that you're in a safe space. This is a comfortable environment. It may seem overwhelming, but don't worry, we're going to go through it in a logical step-wise format, so that you can build on what you've learned previously. And with BNS, in particular, there is this well described phenomenon of neurophobia, and that fear that emotion, can prevent you from doing the very thing that we're trying to do is learn about neurology. So, I think it's a very real and important problem, having too much stress, having too much emotional overlay that can prevent you from learning.
Sydney Larsen: I definitely remember that from the lecture that you gave about the anatomy of the brainstem. And in the beginning, you're like, it's okay, like, we'll learn this over and over again, which was really helpful, because then we were looking at the slides, and I was like, I'm so scared. And by the end of BNS, or Behavioral Neurological Science unit, I felt comfortable with those things, because they did come up, like, every single week, until they were familiar images. I have a question. I hear a lot of people saying, the brain is a muscle. The more you work it out, the better you're able to learn. When people say that, I guess first of all, is it true on like, a neurological level, and then are there new, neurons being made, or is it just the more connections you make, the faster the synaptic connections get?
Dr. Maheshwari: Yeah, what a great question. I think it that analogy is apt and appropriate, but it's clearly not a muscle in the sense of the type of tissue that's involved. We'll just kind of be very clear that we're talking about it as an analogy, and that the more that you get exposed to certain things, that it will reinforce memories and help with learning moving forward. That's definitely true. And I'll tell you that this mindset will help you in your clinical rotations as well, because I think it, it works very well when it comes to seeing patients. So, I'll put it this way, let's say we think about all of what you learned in your foundational sciences, right? You're almost done, basically, right? You're in transition to clerkships now. All of what you learned, I'm going to say that in my experience, there was a grand total unit of, let's say one unit of learning that happened during that time. And then in clerkships, I would say that you get about 10 units of learning. That's an order of magnitude higher, 10 units learning in clerkships, and let's say, throughout the rest of your clinical curriculum, 10 units of learning that you get throughout medical school. And you'll hear this from any medical student who's graduated, or any physician when they think back to medical school they’ll say, oh yeah, I felt like I learned a lot in in foundational sciences, but I really learned a lot whenever I hit the clinical rotations, and then when you're in a residency, I'd say it's about 100 units, another whole magnitude greater of education that you get. And the reason for that, I think the reason I'm telling you this is because it hits at what you're saying, and that is that you're exercising so much more of your brain as you're moving from the foundational sciences to the clinical sciences to residency. In the foundational sciences, it's very theoretical. You're not actually seeing the patients, you're not actually bombarding all of your senses with everything that's going on, that's involved with patient care, then it's limited what you're exposed to. But that's by design. It would be too overwhelming. And it gets to that idea of just you're on the far end of that Yerkes-Dodson curve, if you try to expose yourself too much early on, so it's appropriate that it exponentially increases and it and I think the curriculum here at Baylor helps to take advantage of that, so that your foundational sciences is intentionally shortened to less than a year and a half in order to get you to that learning phase sooner, but not too soon, soon enough that you felt comfortable with at least the vocabulary and the basic principles that you need to approach patients. And then I can tell you, in the clinical rotations, having the mindset of, I want to see as many patients as possible will really serve you well, because the more patients you see, the more you're able to ask yourself, do I really understand this? And you're really able to play that kind of same active learning script over and over again, and say, the encapsulation of what I think of, let's say of a patient with diabetes that has an engram in your, you could call that an illness script in your head. And the more you see a patient with diabetes, a different variation on it, the stronger that engram becomes, over and over again. And the difference then when you go from clinical rotations as a medical student to when you're a resident is that now you're in charge of the patient you're actually making the decisions and the volume of patients that you're going to be seeing increases as well. All of that forces you to really act in a way that brings up those engrams over and over and over again and really consolidates them really nicely. So, to answer your question, I would say great analogy of the brain like a muscle, and I would take that knowledge to help form a mindset where you want to exercise it as much as possible as you go through your training.
Aruni Areti: This muscle analogy that you mentioned is really interesting because it makes sense that in order to build muscle, you have to consistently work and perform certain exercises. But is there ever a point where you're doing too much? Essentially, what role does burnout play, and how do you manage or prevent that?
Dr. Maheshwari: There's no question that you can go too far. And just like within a with a muscle, you can have cramps, you can break the tendon if you exercise too hard, and so I think you do have to know yourself. And I think I'm hopeful that students at Baylor feel like they have the support they need between the Office of Student Affairs, your Learning Community Advisor, your specialty mentors, your peer Resource Network, your PRN groups, your own friend groups that you might have, all of the mental health services that are available both within Baylor, and then also the line that's available outside of Baylor. All of these are intended to help prevent that from happening and I think it's important for everyone to be aware of them, not just for themselves, but if you notice that one of your friends is struggling, that you're able to provide them with that support as well. So absolutely, it's something that, given the pressures and the stresses of medical school, we want to make sure that there’s safeguards to prevent that burnout from happening.
Aruni Areti: Absolutely, Baylor has done a great job providing great resources to counteract burnout and mental health, and I'm very fortunate to be an institution that supports us like that. But now I'm actually going to transition into a question I'm very excited to ask you about, and I'm sure our listeners are too, and that's related to Anki, for our listeners who may not know what that is, Anki is a flashcard application that is extremely popular among medical students across the nation, and so I'm curious to say, Look, what's your take on it? Is there a right and wrong way to use it?
Dr. Maheshwari: I think it's popular for a reason, and it's because it works. It helps you have a structure to the very process that we were talking about before of how memory works. It allows you to have this kind of spaced repetition and active recall, quizzing, of the specific engrams in your brain that you really want to make sure are consolidated. And so, I think it can be very helpful and very important as a part of your toolbox for studying. In terms of where it could go wrong. I think there is a potential, and I'm hopeful that most students learn this on their own or have been told by other students. But the way it can go wrong is if it's really only being used as a mechanism to make sure that you you've memorized facts. That's the problem. If you're going through your Anki deck and you're and you're hitting next, next, next, you're like, got it, got it, got it, got it. And you're not taking the opportunity to ask yourself, do I really actually understand this? There's a difference between getting the question right and actually understanding it. If you see a question enough times, you'll get it right simply because you've made the association in your head without necessarily understanding the underlying concept. So, for the example that we used earlier, is, you know, glutamatergic neuron, excitatory. You might get that question right by saying that, okay, the question stem asks, “What neurotransmitter does an excitatory neuron make or produce?” And the answer was, B - glutamate. You might have gotten that right. But you really understand what an excitatory neuron is, do you recognize that the glutamate then goes from the presynaptic to the postsynaptic neuron, and it's the fact that it causes the postsynaptic neuron to depolarize, which makes it excitatory? Or have you just made the association that excitatory glutamate and not really understood the larger concept? So, bottom line answer to your question, I think, is that Anki is a great way to ask yourself, to take the opportunity to say, okay, I got the fact right. But I think it's more important to take a pause and say, Do I really understand this concept? And if not, that's where you can go back to the source and say, okay, I don't really understand what even excitatory means. Let me go look that back up again and make sure that make sure that I could, for example, explain this to somebody else.
Aruni Areti: An upperclassman once told me that during clinicals, if you broke down a very big clinical question to 10 small questions, i.e. just Anki flashcards. We could answer them pretty easily, but putting them into clinical application is the tricky part, and that's the part where we really need to make sure we're getting to when we to when we do Anki. This kind of leads to my next question, which is, are there any common myths students believe about learning that you could debunk for us?
Dr. Maheshwari: Sure, sure. There are probably two that come to mind. The first one is that learning should feel easy, that if it's feeling hard, that you're doing something wrong. I know I felt that way when I was a student. I felt like if I was struggling to understand something, that it was on me, that what's wrong with me, why can't I just figure it out? It seems like everybody else is figuring it out, and what I didn't realize until later. And I think there's an important part of PBL. The problem-based learning approach that you guys have been exposed to is that confusion, that not understanding at first, is part of learning process, and it's super important, because if you're never feeling that, then there's something wrong because you're not actively challenging yourself about how you understand things. And so, what I really like when I've sat in PBL is I can see that happening. I can see students struggling. And I have been told by students, I don't think this PBL is working. I think that it would have been so much easier if you just told me what I need to learn and I get it. I get it. I totally get it, because I remember feeling that way as well. But what study after study shows is that it is that process of figuring it out for yourself that ends up leading to the most robust educational outcomes. There is a challenge though there, because we can do it wrong. Let me be clear. There is a problem of too much confusion. There is a problem that comes if there is no direction that's being given and it's completely out in the wild west, and you have to try to figure it out on your own. That's problematic if you have no facilitation and no ability to make sure you're going in the right direction, then that's even worse than being told what you need to learn. There is a term that's been called optimal confusion, which I think hits at what we're trying to get at. You want to be in that optimal confusion zone so that you can then come to that conclusion without having too much distress.
Sydney Larsen: I feel like we've been talking about like, that upside-down, U-shaped curve a lot. I feel the theme I'm seeing is moderation is everything, you just want to be in the middle, like, not too little, not too much, and that's where you can optimize how much you're learning.
Dr. Maheshwari: I'm with you. Hey, it works for eating as well. I'm telling you, I have a problem with if I have food in front of me, I will eat all of it, even if I probably shouldn't. And so yeah, I agree with you, that kind of middle path has a lot of advantages.
Sydney Larsen: I know that we've talked a little bit already about your experience with designing, not only our overall curriculum here at Baylor, but specifically the Behavioral Neurological Sciences unit. When you helped redesign the unit for us, how did your understanding of learning shape decisions that you made, out of the ones that we've already talked about throughout this episode?
Dr. Maheshwari: What a great question. So first, I have to give credit to all the folks in the curriculum renewal work group who ultimately came up with the design of the course. It definitely was not my idea to combine the Behavioral and the Neurologic Sciences course when I heard I said, Well, of course, that makes a lot of sense. It's an artificial line that's there to begin with. And one of the principles of the curriculum renewal work group was integration, integrating different components that were previously in silos, and so, that was, I think, one of the advantages of the of the shift in the curriculum. The other thing that I think was done very intentionally, that I didn't have a part of initially, was using an outcomes-based approach. And so, this is well documented. It's been published. It's a procedure called Understanding by Design, where, instead of saying, which seems like it might be a good idea, saying, Okay, we're the experts in behavioral neurological sciences. What do we want to teach everyone? Let's put all these together. We should have a session on X and then also a session on Y, and then, don't forget a session on Z that's so important. We know that if we try to do that, it's impossible, because there's just so much out there, and there's so much that we would love to teach, right? But instead, what the curriculum renewal work group did was they said, What do we want the students to be able to know? What do we want them to be able to do by the time they're done with this course and then work backwards from that. And so, using those outcomes, they came up with the particular assessments that would then make sure that you've achieved those outcomes. And then from there, work backwards to, Okay, so these are the sessions that that we'd want to put together. And then I came in late into the game, after that initial infrastructure had been placed, along with our CO course directors, and then when we looked at it, we only made a few recommendations about changing the order of things. But the piece that we took from the legacy curriculum and continued with the new curriculum is this idea of scaffolding. This idea of starting with the very basics in a way that wasn't too overwhelming, just saying, Okay, this is the overall structure and function of the nervous system, and don't worry. This is overwhelming. I think I said, do not worry. Like 1000 times in week one, do not worry. We will revisit this. And then we took it portion by portion within the nervous system. And then we said, Okay, now we're going to focus on this. And then, to your point, I think earlier, we tried to make sure that anything that was brought up was brought up in the context of what you've already learned before, and not just, Okay, we're done with that. Now we're moving on to this. I think that fits in with the concept of how learning works best when it's associated with something else, as opposed to in isolation. That's the term a lot of people use, interleaving. If you're interleaving as opposed to saying doing sequential learning, then that that tends to increase the outcomes as well.
Aruni Areti: Yeah, I was actually really curious, what were some of the decisions that were really difficult when you guys were developing the curriculum, I'm curious to see, what were some of those challenges you guys actually faced?
Dr. Maheshwari: Yeah, oh no, no. I mean, almost every decision I think was difficult, that's a great question. And there was a lot of debate, a lot of weighing of the pros and cons. Have to give a lot of credit to Dr. Christner, Dr. Ismail, the deans of the medical school, who really had a vision of saying, nothing's off the table. Let's, let's start from what has been published, and let's be innovative. Let's think of ways that we can improve on what's already out there. Because I don't think anyone would say that there is a perfect curriculum out there. If there was, we would copy that, obviously. And so there were a lot of opportunities. So. I'll give two examples of ones that were, we were a little worried that this is brand new. It seems like a good idea. Nobody else has done it before. Should we do this? And ultimately, with both of these examples, we piloted it first, just to make sure that it was well received, that it had the intended outcomes that we wanted, and then we implemented. So the first you might, I wasn't really involved with the development of this, but I think it was a great addition is the AM/PM exam every two weeks right, where you get the first opportunity to answer 40 questions in the morning, then you have a couple hours to focus on the areas where you immediately found out that you were deficient and you weren't able to get those session objectives correct. Then you could go focus on those and then come back in the PM and retake another 40 questions, same session objectives, different questions, and then whichever one you do better on is the score that counts that was based on the underlying theory that that guided the whole curriculum, the idea that assessment should be for learning. You shouldn't just wait until the very end of a rotation and then say, Okay, do I understand this? You should be able to have the opportunity to ask yourself, Do I understand this frequently, and that supports the formation of those really strong, consolidated engrams? So that was number one. And number two was this principle of space repetition, you know, you're doing it frequently over time. So, all of that, I think was helping to be consistent with what we how we know the brain works. That was the first example. The second example you haven't seen yet, but you will soon, and that is in the clinical curriculum, we introduced what's called the two step process. And so typically, as you may have heard, whenever you are seeing a patient, your faculty might observe you doing something like taking a history or doing a physical exam. And then what we know was already happening was that faculty were giving you feedback. They were saying, Hey, you did this well, and here's what you can do to improve. And the way that had always been documented was that the faculty would have to document that at some point. You, the student, would launch the forms, they would go to the faculty's email. They'd maybe get to it a week later or so. And then when they do and they're supposed to write down, what did you do well? What could you do to improve? Oftentimes, it's very generic. And probably, I know I was in this boat, I had difficulty remembering what was it exactly that they did. I remember there were four students that I was with last week. Was this the one that did this well? And because I couldn't necessarily remember very well what was going on, I couldn't give very high-quality feedback when I was documenting it or build on what I might have said in the moment. And so we created this two-step process. This was a risk. We started with having the student document what it was that they did well, what they were told they did well, and what they were told they can do to improve. This really primed the students. I'm seeing students now walking around with notepads so that they can write down what it is that's being told to them, so that they can remember and document it. They typically do it the same day, and then when I get around to it, maybe a week later, I'll see what they had written down, and it'll jog my memory, and I'll say, Oh yeah, that's right, I did say that. And I, you know, we were in a hurry that day. We had a lot of patients. I also wanted to say this. I just didn't have the opportunity, I can document it in the moment later. And we studied this, and we found that the quality of feedback and the quantity of feedback both significantly improved with the with this two-step process. So, then we were happy to make that large scale. Of course, that came with a lot of challenges. We needed to have the technology that was able to enable that two-step process. The system that we had didn't innately have that. We had to create that. But I think the return on investment was very good because we're seeing such an improvement in the feedback that students are getting.
Sydney Larsen: I think I can really see throughout the curriculum how much thought and energy was put into each of the things that we do throughout the year. And it feels really cool to think that this entire team of people work together to kind of create a better education for people like me.
Dr. Maheshwari: I appreciate that. Thank you, and I think I don't want to take anything for granted. There is a chance, as you mentioned, this is a risk. There is a chance that these could not be perceived as they were intended. There's a chance that this could be perceived as just another check box. That is the bane of any curricular innovation is the possibility that students and faculty only see it as, Ah, they're making us do this now. And so that is something we need to keep a very close eye on, and something that I think we're asking constantly is that, is this having the intended consequence? Are the students learning more? Or feeling like they're learning more? Is this interrupting the clinical workflow and causing more of a burden than it is actually helping with education. These are things that we're going to have to continue to monitor so that we can improve, year after year.
Sydney Larsen: This education process is the same thing that you went through, and I feel especially for you, because you got your medical education at Baylor, I can only imagine it must be kind of interesting. You were once exactly in our seats, actually in the same auditorium. So did anything surprise you when you started thinking about the curriculum from the educator side instead of the student side?
Dr. Maheshwari: I'd say that I was blissfully ignorant as a student. I am so excited to see you guys asking these questions, and when I see students who are so interested in medical education, it blows me away, because I did not question. I just said, Surely these folks know what they're doing, and surely the way they're teaching us is the best way. Because I'm at Baylor College of Medicine, so it's got to be the best way that they're teaching. And it made sense. And you know, the had these experts in these fields teaching me something, and I was gobbling it up. I was saying, Okay, I'm going to learn this. And I think I was, I slowly learned how to learn over medical school, the first couple of blocks, I think I had challenges. I was used to that cramming and then regurgitating, and it didn't work very well. It was only after a couple of months, I started to realize, okay, I need to actually quiz myself. I need to figure out whether or not I understand this. I can't just try and memorize. And I think I had that, as I mentioned before, that perception that 90% of it was on the teacher and not on me. And then to answer your question, what flipped, I think, for me, whenever I was in the teacher role was that I, let's say I was preparing a session for students. I was not motivated by making sure that the students learnt the material. I was scared. I was worried that they would think that I was some kind of imposter up there trying to teach them. The first couple years, I felt like I needed to prove to students that I knew the material. And I felt I did a successful job at teaching if at the end of it, I reflect and I said, Yep, I got that right. I did it, and then the students would, I could tell in their eyes, like, okay, yeah, that made sense. And I can say, okay, yes, they know that I know the material and success. And then it was only, like, after a couple years, I started to realize, wait now, that's ridiculous. They don't need to know that I know. I need to know that they know. I need to know that they've learned it. And so that's when I started introducing questioning, asking questions in it to see, are their wheels turning? Are things making sense? And with BNS, you guys saw, for example, the Phantom Four strategy, which was really my way of understanding, are they getting it? Do I need to spend more time on this topic because most of the students didn't get it right? Or am I okay to move on and go to the next topic? And so, I think to answer your question, that's what shifted most, was that I didn't realize how much, how important it was for the professor of a class to get into the mind of the learner.
Sydney Larsen: Could you really quickly explain the Phantom four for anyone who doesn't know what it is?
Dr. Maheshwari: Oh yeah, sure, sure, sure. So the idea is that we have always wanted to emphasize active learning as much as possible, and that means engaging students in the process of an activity that questions whether or not they understand the material right. And so those can be challenging, with lots of opportunities for technology to be to be integrated into it, but I found that, for example, Poll Everywhere, I think it's a very powerful tool, but it was slower than I wanted it to be. I wanted to kind of move through things a little bit faster. And so, we came up with the Phantom Four process, which was, I would ask a question, the question would be on the slide, and then it would have multiple choice answers, 1234, for example. And the students would get a chance to think about what the answer is, and they would have that answer in their head. And then I would basically poll the class by saying, on the count of Phantom Four, tell me what your answer is. And the way that works is I will say one, two, three, and then when I would say four, there's that imaginary time where I would say four, that's where everybody says their answer. So, I think it was helping people get on the peak of that Yerkes-Dodson law inverted U-curve, because it's a little bit stressful. There's a couple of people around you that might hear what you're saying and so they might hear you say the wrong answer. But it wasn't so bad, because not everybody could hear, just a few people, and so kind of hopefully getting you right in the middle of that curve. And so, I'd say 123, and then I'd hear the answers, and then maybe 50% of class would say two, 50% of class would say four. And then I'd get a sense of where everybody was at. I'd say, okay, I can see why you might have picked that, and that's because of this or that, but here's why the other one was the correct answer, and so does that help?
Sydney Larsen: Yeah, yeah. Thank you for that. My next question is, how has your research or clinical work influenced the way that you teach, or has teaching in any way shaped your clinical/research perspective?
Dr. Maheshwari: Yeah, great question. I think it's definitely bidirectional. I've been very fortunate, I think, to see a lot of what I do on the research side translate to what's going on the education side, and vice versa. And I think that's culminated more recently in the past three or four years, in really doing more education related research. So, for example, researching about the two-step process, or looking at, for example, the introduction of artificial intelligence into the MSPE process, writing your Dean's letters, for example, these are all things that I think I learned a lot how to approach research through my work with mouse models of epilepsy, and that translated really nicely to the education world.
Sydney Larsen: I've recently heard through the grapevine that you're stepping away from your position as a course director. What's next for you?
Dr. Maheshwari: Thank you. Yes, it was hard. I mean, I can't think of a thing that I've done that hasn't been hard here at Baylor. I really enjoyed being a Learning Community Advisor, but I needed to step away from that in order to focus more on my curricular efforts. And same thing with the Behavioral Neurologic Sciences course. I was course director for that, I think five years previously, it was the nervous system course, after taking over from Dr. Goodman and I think now I've shifted over, as of July, I've been promoted to Assistant Dean of Curriculum, and in that role, it is more time and effort of overseeing the overall curriculum, and so I was happy to have Dr. Bellows kind of take my position as the kind of neurologist on the team. And so, he's now the co-course director, along with Dr. McMillin from the Temple campus and Dr. Idicula as well. So, a good mix of a neurologist, psychiatrist and neuroscientist, all with excellent teaching skills and leadership skills, and so I firmly believe they're going to continue to keep the course amazing and make it even better. I'm not leaving from the course. I'm still planning to if, as long as they'll have me continue to give a lot of these sessions, like the one on memory and the basic science of learning, but now most of my effort is with the Office of Curriculum as Assistant Dean.
Aruni Areti: Well, I can definitely say, on behalf of all Baylor med students that we are lucky to still have you teach parts of BNS, and I can safely say your footprints in BNS will have a lasting impact on the course.
Sydney Larsen: I was curious, do you have any big plans for, I guess, the next couple of years in your new role?
Dr. Maheshwari: It’s still very early for me. I just started, so I'm still learning a lot about how the curriculum works. I think we are now in a phase of continuous quality improvement for this curriculum that still has so many opportunities to innovate, and so I'm really excited about the potential to build off of what we've what we've done so far. I think probably the most exciting part is all of the new opportunities that are coming with artificial intelligence to really help integrate all the pieces of the curriculum together. I think for me, what I've you know, again, relatively new in this position, what seems the most challenging with the curriculum is each of the components of the curriculum understanding what's going on outside of it. And so, I think there are opportunities to kind of thread things through the curriculum. And one of the innovations of the of the curriculum are the introduction of threads. And you've seen that there are thread directors who are helping to make sure that there are themes. That are consistent throughout your curriculum. So, I think there's a lot of opportunity within that to continue to improve.
Sydney Larsen: Awesome. Thank you so much. If any of our listeners or students want to learn more about medical education, your research or the curriculum or connect with you at all, where should they go to?
Dr. Maheshwari: The easiest way is to email me. So A-T-U- L, dot Maheshwari, M-A-H-E-S-H-W-A-R-I@bcm.edu. I encourage anyone to reach out. I'm always happy to talk about anything curriculum related or actually anything at all. Always happy to talk.
Sydney Larsen: Thank you so much for being here today and taking the time to talk with us and give us all this good advice and tell us about the curriculum. We really appreciate it.
Dr. Maheshwari: Thank you. I had a lot of fun.