PGY-3 Neurology – Queen's University
I’m Bryce Durafourt, a PGY-3 in Neurology at Queen’s University. I was born in Montreal, Quebec and attended McGill, where I received an honours B.Sc. in Microbiology and Immunology (2009); M.Sc. in Neuroscience (2011); and, M.D., C.M. (2015).
During my undergraduate training, I completed an honours thesis project in neuroimmunology under the supervision of neurologist Dr. Jack Antel at the Montreal Neurological Institute. I became fascinated by the implications of basic science research on clinical practice, as our lab worked on the pre-clinical development of a novel oral multiple sclerosis treatment. I continued on to complete my Master’s degree in the same lab, and, under Dr. Antel’s mentorship, I discovered my passion for neurology.
What does a typical day of clinical duties involve?
A typical day is variable depending on the rotation. Earlier years of training are more focused on ward rotations, with more clinic based rotations in subsequent years. A typical day on the neurology or stroke ward begins at 8:00 am, with handover from the resident on call overnight.
The senior neurology resident assigns ward patients to junior residents and medical students to round on, and also accepts consults from other services and the emergency department. The senior resident is responsible for rounding on critically ill or unstable neurology patients admitted to the step-down ICU. I also field phone consults from family physicians and specialists in the community and from peripheral hospitals.
The team often meets with the staff neurologist to round and do teaching at 11:00 am. Consults are seen by junior housestaff and reviewed in the afternoon. There are also numerous dedicated teaching rounds, with Thursday morning protected teaching time for neurology academic half day.
Neurology residents are responsible for performing or supervising various procedures, including placing nasogastric feeding tubes, performing lumbar punctures, and assisting in running acute stroke protocols, pushing IV tPA when indicated. There is a focus on interdisciplinary care, with a close collaboration with nurses, physiotherapists, occupations therapists, and speech language pathologists.
At the end of the day, the senior neurology resident hands over the care of admitted patients to a junior medicine resident on call. Neurology senior resident call is home call, with approximately 1-2 weeknight calls per week, and 1-2 weekends per month. The on-call neurology resident performs inpatient and emergency department consults, fields external phone consults, attends all acute stroke protocols, and acts as a backup for neurology issues on the ward.
What kinds of rotations are required in your program?
The first year of training in neurology residency is usually focused on completing core internal medicine rotations, including medicine wards and various subspecialties, as well as rotations in geriatrics, palliative care, and emergency medicine. The second year includes rotations in intensive care, neurosurgery, and then a focus on neurology wards (both stroke and general neurology). Third year includes neurology wards, 3 months of EEG, 3 months EMG, clinics, and elective time. Fourth year includes 3 months of pediatric neurology, additional neurology wards, and the opportunity for research or elective rotations. Fifth year involves neurology wards (including as the “junior attending” role), clinic rotations, and of course the Royal College exam.
Which of your personality characteristics have been particularly helpful in your field?
Traditionally, neurologists were viewed as mangers of patients living with chronic diseases (epilepsy, Parkinson’s, multiple sclerosis, etc.) and as such, the focus was (and still very much is) on building the doctor-patient relationship. Neurologists advocate for resources for patients and their caregivers, and patience is most certainly a virtue. The ability to remain calm in high-stress situations is critical in neurological emergencies, such as when treating patients with status epilepticus or during acute stroke protocols. Finally, being an efficient manager and a good team-player are skills needed for running an inpatient ward – in neurology or any discipline.
What are the best aspects of your residency?
Neurology is a rewarding field primarily because of the connections we make with our patients on a daily basis. Effective management of chronic diseases such as epilepsy or migraine can truly impact a patient’s quality of life, and seeing that transformation is rewarding. Even for patients with incurable disease, having their symptoms explained by clinical localization, and often simply believed, leads to incredible gratitude. While the unknowns in the field can be frustrating, this also allows for a world of research possibilities and an opportunity to contribute to the advancement of the field.
What are the most challenging aspects of your specialty/subspecialty?
While all clinicians must learn an incredible amount during residency, the intricacies that neurologists need to know at times seem endless! A solid understanding of neuroanatomy is needed to be able to understand the clinical syndromes and common presentations, and the need to also know the uncommon and rare presentations can be challenging. As our understanding into the genetic basis of many neurologic diseases continues to evolve, so too does the list of alleles and mutations that we must be able to recognize.
What is one question you’re often asked about your specialty/subspecialty?
“Are you frustrated that neurologists are often helpful at coming to a diagnosis, but have little to offer in terms of treatment?”
In response to this, I often tell people that neurology is one of the most rapidly advancing fields. For example, multiple sclerosis patients now have more than 14 approved therapies to choose from, compared to only two injectable options available a decade ago. Patients with epilepsy are seeing better control of their disease by using newer agents with fewer side effects. Finally, the care of patients with stroke is being revolutionized by endovascular thrombectomy (clot retrieval), and it is up to the neurologist to recognize when a patient with stroke symptoms may benefit from this potentially life-altering treatment.
Can you describe the transition from clerkship into residency?
Our academic half-day curriculum includes a two-month “boot camp” focused on neurological anatomy and the clinical exam, providing the foundation for subsequent learning. There is also a graded responsibility, with junior residents having access to adequate senior resident back-up, and staff always available for the more senior trainees when needed. In all fields, the first day of call as a “real doctor” can be overwhelming, but there is always someone to help so that junior residents should never feel unsure or unsafe in their decision making.
What are your future practice plans?
I am planning to complete subspecialized fellowship training, possibly in vascular neurology (stroke). I am hoping to have an academic practice as a neurologist, and I hope to continue to be involved in medical leadership as a staff physician. Later in my career, I aspire to take on health care administrative positions, where I would hope to make systems level changes to care delivery, but I would always want to maintain a level of clinical practice.
What are your fellow residents like and how do you interact with each other?
Neurology residency training programs are generally quite small, with 2-3 residents per year in most programs. The Queen’s neurology residents are a tight-knit group, and we regularly turn to each other for advice and support when needed. We are lucky to be friends outside of work, and we all rent a house together when we attend the annual American Academy of Neurology meeting.
What are your academic interests?
I have a strong interest in medical politics, having served as President of the Canadian Federation of Medical Students, and now act as Treasurer and member of the executive committee of Resident Doctors of Canada (RDoC). I have also sat as a member of the Professional Association of Residents of Ontario (PARO) general council, and currently serve on the board of directors and executive committee of the Canadian Residency matching service (CaRMS). My current research interests include workflow optimization and the impact on door-to-needle times in acute stroke care.
What is your work-life balance like, and how do you achieve this?
In the summer I enjoy road biking, and in the winter I enjoy watching hockey (both the local Kingston Frontenacs as well as my long-time favorites, the Montreal Canadians). My wife, family, and friends all help to support me through the harder times of residency, and help me celebrate the successes.
You can find Bryce on Twitter @durafourt.