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Teaching clinical neurology
  1. Chris Allen
  1. Correspondence to Dr Chris Allen, Neurology Department, Addenbrooke's Hospital, Hills Road, Cambridge CB2 0QQ, UK; cmca100{at}cam.ac.uk

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‘No bubble is so iridescent or floats longer than that blown by the successful teacher’

‘The successful teacher is no longer on a height, pumping knowledge at high pressure into passive receptacles…he is a senior student anxious to help his juniors’

Sir William Osler (1849–1919)

‘Neurophobia’ has been a subject of interest over the years since Jozefowicz coined the term in 1994.1 Neurophobia is at least partly caused by inadequate neurology teaching, teaching that may be inadequate in quantity and/or quality.2 To improve the quantity of neurology education neurologists must get involved in the organisation of curricula in their medical school, as some have done.3 To improve the quality of their teaching neurologists need to reflect upon what makes a good teacher and/or what makes a bad teacher.4 5 We can learn something from the work of medical education specialists who try to understand the processes by which students learn.6 7 However, we should use this educational theory like a condiment, appropriately but sparingly.

Changes in clinical practice (fewer and fewer neurology inpatients, more and more outpatients with less and less disease) are producing pressures on clinical teaching, which has always had to compete with working clinicians' other tasks. However neurologists (and their managers) should recall that originally the word ‘doctor’ meant ‘teacher’ and therefore teaching is part of the core duties of a clinician. To teach well is good doctoring and teaching clinical neurology well will allow neurophobia to become a thing of the past.

What makes a good clinical teacher?

A clinical teacher's main job is to equip students with an enthusiasm to learn neurology. Clinical teaching is not about the passive of transfer of knowledge from teacher to student. Good teachers inspire, entertain and support their students in their learning. The word ‘educate’ (from Latin ‘e’ + ‘ducere’, to lead out), like the word ‘educe’, means to ‘bring out, develop from a latent condition’. The word ‘train’ (from Latin ‘trahere’, to draw out) refers to dragging or trailing something, usually behind you. Clinical teaching is about bringing out, not dragging behind; dogs and horses can be trained but medical students also need to be educated.

Clinical teachers are privileged to teach students who are, by selection, among the most intelligent and highly motivated in the country; so a failure for them to learn is the fault of the teacher and not the student. Some teachers feel that their job is to lay out polished pearls of wisdom and then call students ‘swine’ if they do not appreciate the beauty of the offering. Students will be bored and therefore not learn from you if you are boring as a teacher, no matter how pretty you think your pearls are.

Many excellent teachers have had no training in teaching but bad teachers can be improved to reasonable teachers by being taught to teach. Everyone's teaching can be improved with reflection upon what they are doing when they teach. The good clinical teacher will teach with the students' perspective in mind.

Learning clinical medicine is a process of the progressive layering on of knowledge and skills, like a clay sculpture which only has the vague frame of a shape before the full form becomes evident as successive pieces of clay are applied and integrated with the final form. No one appreciates an art master who constantly rubbishes your efforts at sculpture; learning the joys of clinical medicine should be a positive experience, even if one's early efforts are misshapen.

How to teach clinical neurology?

There are many ways of teaching successfully and different styles of teaching suit students with different styles of learning.8 However, there are some principles by which most good teachers are guided:

  1. Know what the students might be expected to know already, that is, what stage they are in their course.

  2. Know, and let them know, what you expect students to learn in their time with you (educators call these ‘learning objectives’, which are now characteristically corrupted by medical students to ‘LOBs’) (Allen S J C, personal communication).

  3. Encourage active learning through problem solving rather than passive fact accumulation. Relevant facts will accumulate through the problem solving activities.

  4. Criticism should be constructive. Bullying students is seen as a sport by some teachers but does nothing of educational value for the victims.

Most clinical teachers are happiest with the ‘Socratic’ style of teaching in small groups, which is offered by ward rounds and clinics. This is the mode of teaching that medical students appreciate the most too. Most clinicians are least happy giving didactic lectures, which in turn probably have the least educational value to clinical students.

The primary purpose of my teaching ward rounds, I tell students, is to get them thinking about how to use the neurological examination and use it to make sense of the history, not for me to teach them didactically about diseases. Of course, diseases will be discussed, but when students come across a disorder they have not heard of, I urge them to make a note and look it up later in the library (or try Wikipedia or Medscape on their Smartphone). Ideally, clinical teaching should be with actual patients but changes in clinical practice can make this difficult, so it is wise to have some virtual patients to show on your laptop or tablet; videos of patients with abnormal eye movements and movement disorders are particularly good for this.

With new referrals in outpatients, I emphasise that we are mostly learning about patients' histories but here you can also teach the use of your short screening neurological examination. Opportunistically you can teach other things, for example, young patients with tension headaches are useful material for students to practise their ophthalmoscopy; and there are plenty of clinical signs especially in follow-up clinics. Follow-up clinics also offer the opportunity to discuss the assessment of disability, the management of chronic disease and the real life pharmacology of epilepsy and Parkinson's disease.

Teaching clinical neurology as neuroscience based problem solving

Problem solving can only be learnt through experiencing the task of solving problems with the teacher as a knowledgeable guide. By the time neurologists meet clinical students they will have encountered much clinically relevant neuroscience, usually hidden among much clinically irrelevant neuroscience. They can be guided to recover sight of the relevant wood from the trees and use their knowledge to solve a clinical problem.

For example, when shown a pair of spastic legs, students can be reminded that in testing tone (and tendon reflexes) they are testing the reflex response to stretch. They can then be guided back to remembering those funny little ‘muscle spindles’ with their nuclear bag and nuclear chain stretch receptors that respond to speed and degree of stretch. ‘Oh yes, and see, you can stretch spastic muscles slowly but not fast !… what sets the sensitivity of these reflexes?… what about those intrafusal muscle fibres with their very own gamma efferent fibres? They seem to be rather uninhibited here, like drunken students!’ Then, knowing that they have learnt about neurotransmitters in a series of dry pharmacology lectures the students can be asked, ‘how would you reverse these excessively active gamma efferents and help the patient’s spasticity?'…yes, by increasing the inhibition on these neurons…yes, by using a GABA-agonist, it's called baclofen, here it is on the patient's drug chart'. In such a discourse, the students are not being presented with any new knowledge but being allowed to see the usefulness of knowledge they already have in understanding clinical phenomena.

Teaching the neurological examination

In teaching how to examine the nervous system a clinical teacher comes up against one of the pillars of neurophobia. The students always look relieved when I tell them that no one ever completes a ‘full neurological examination’ (even if anyone knows what this is). I ask the students to think about why they are examining the nervous system, since only then will they be able to say what they want to examine. Then I ask them what reasons there might be for examining patients, ending up with the following list:

  1. To test diagnostic hypotheses generated from history taking (patient with double vision, examine the eye movements).

  2. Screen for unsuspected neurological signs (so they never write ‘CNS grossly normal’).

  3. Baseline for the future (eg, in a patient thought to have Guillain–Barré syndrome: ‘yesterday he did have arm reflexes today he doesn’t').

  4. Give you time to think about the history and management while the patient is not supposed to be talking.

  5. Because the patient expects it (it is what doctors do) and it gives him/her the perception you have taken their problem seriously (‘that nice young doctor gave me a very thorough examination, even listened to my skull!’).

Students usually quickly supply the first three reasons but need more help in arriving at the last two.

I then ask them to develop a neurological screening test, which with guidance ends up looking like the one I use in the clinic. I then point out that like all screening tests, they need to know what abnormalities this screen could miss (ie, have a feel for the sensitivity and specificity). I tell them that I expect them to become confidently competent in this because this may be the only neurological examination they ever subsequently use. The opportunity to understand more complex signs comes later as they go through their clinical experience but a few signs I do specifically make sure they can cope with:

  1. Difference between upper and lower motor neuron lesions… ‘it’s all in the reflexes'.

  2. Significance of nystagmus (=brainstem lesion, ‘you students won’t be up in time for peripheral vestibular nystagmus to still be present'). They learn that the word nystagmus is Greek for ‘the nodding of the head when drowsy’ from Nyx the Goddess of night, ‘Like the hung-over lads in the back of the lecture theatre or the middle aged professor in the department meeting’ (slow drift off and rapid return to target).

  3. Third and sixth cranial nerve palsies (complete ptosis is third nerve palsy or myasthenia) and internuclear ophthalmoplegia (‘the only subtle sign in neurology which has anything other than subtle significance is the perceptible slowing of adduction on horizontal saccades’).

  4. How to see the optic discs and recognise normal fundi; on average 30% of my students can see retinal venous pulsation by the end of the attachment, but the rest learn about funduscopy looking for it.

  5. Different gaits (multi-infarct, Parkinson's, spastic, neuropathic, ataxic, myopathic, hemiplegic). Most neurologists can act these out if the right patients are not available.

  6. The difference between ‘confusion’ and fluent dysphasia (John Marshall used to forbid his Queen Square SHOs (senior house officers) to use the word ‘confusion’).

Being observed examining the nervous system is an essential part of students' education in neurology, even if most do not like it. They need to learn that in real life all examinations are carried out under observation, even if only by the patient. Practically, students need to realise that how you approach doing the reflexes or use the ophthalmoscope will entirely give away lack of competence to an observer in an exam or later in front of your boss or even later still in front of your juniors.

As neurologists we all know that different parts of the neurological examination have different diagnostic value in different circumstances, which is why we never do a ‘full neurological examination’ (whatever that is) in any one patient. Therefore, rather than making students examine the nervous system in a rote order, I try to make them understand the relative importance of some signs over others in different circumstances. So, given a patient who evidently cannot move her legs, I ask the students if they can perform one aspect of the examination only to clinch the case, ‘as if we were running out of time’ (the answer is usually the reflexes). Or, somewhat more sophisticated, if we have concluded that the patient has a thoracic cord lesion (upper motor neuron legs and normal arms), what one part of the cranial nerve examination should we do, if we are running out of time? (The answer is the eye movements.)

Doing tendon reflexes (‘should be called muscle stretch reflexes’) seems like an easy task but is an area with which students struggle regularly. It can be explained that the action comes from the wrist, just as in percussion of the chest, the muscle spindles need to be subjected briefly to an undamped square wave mechanical stretch (as near as one can make it). In a very spastic leg, one can demonstrate that tapping half way down the tibia is enough to fire the oversensitive stretch reflex in the quadriceps by spreading of the brief vibration through limb (and percussing the tibia with your finger can do the same, demonstrating that it's all in the wrist).

When watching students examining the nervous system, teachers should carefully observe the mistakes made or poor technique employed to improve on their teaching, not to make the student feel foolish and inept. We were all inept at these skills once. Making students feel foolish and practically inept is a form of abuse, which, quite correctly, students will recognise as such and switch off (switching on their neurophobia).

Communication skills

While teaching students with patients, clinicians are unavoidably teaching them attitudes towards patients. If you teach on a patient as an object with clinical signs, you are encouraging students to dehumanise their patients. So I make sure that the patients remain involved, usually with a bit of banter and apologies for ‘treating your legs (etc) like lumps of meat’, and the like. I also ask the patient at the end of the session if he/she has any questions arising from the session and then get the students to answer, thereby testing their communication skills (and mine). I also emphasise to the students that one must evolve a ‘patter’ to communicate to the patient what is required of the patient being examined neurologically (‘remember when we examine their nervous system, we do get patients doing things which must seem pretty strange to them!’). Thus, students will learn that to communicate adequately with patients you have to see the situation from ‘the patient’s perspective' and this applies even to examining them neurologically. Similarly, a lot of our neurology outpatient work involves explaining things to patients and students will learn how to explain difficult neurological phenomena to patients from your example, so make it good!

Teaching the value of the history

No matter how many times they are told (and I was the same), students take a long time to appreciate that most of the skill in neurology is eliciting (or educing) a good history. They should learn that while anatomy and physiology are used to decide where the lesion is, the history is essential in determining the pathology.

One way in which I demonstrate how impossible it is to get to a diagnosis without a history (and often how impossible it is not to have any history) is by asking students to make a diagnosis only from the examination findings. So, at the end of 30 min or so of examining different parts of a patient's nervous system, after we have elicited all the signs and know that the patient has a spinal cord lesion, I ask a student to ask one question about the history (‘because of healthcare rationing only one question allowed’). This means that students have to think about what the most discriminating question might be (it is usually ‘how and how long ago did this all come on?’).

An alternative way of teaching the value of the history is to ask the patient to recount their history warning them that you will be interrupting them repeatedly to ask the students what they think is going on. Then after every few sentences, ask the students what they think the diagnosis is. But first I ask a student what the diagnosis is before the patient starts talking. Here the student has to use the patient's evident age and gender as well as any clues around the bed to start hypothesising using epidemiologically based a priori likelihoods. This demonstrates the active way in which we think of the history, hypothetical diagnoses rising and falling in our minds as the story unfolds. If this type of exercise is put next to the one above, it can be shown that analysing the history gets the answer much quicker than just examining the patient (or just doing a scan for that matter).

Conclusion

Educationalists can explore the different ways in which students learn and this often explains why clinicians liked or did not like the teaching they had in the past. If you do no more than emulate the teachers who taught you well, you may not need to know any educational theory to be a good teacher. However, understanding the processes that underlie a student's successful learning can make your teaching even better. The prime requirement is to be interested in the students and to make your teaching interesting to them. It is your fault, not theirs, if they learn nothing from you.

Acknowledgments

The author acknowledges the immense contribution of his past teachers and past students from whom he has learnt a great deal. The author also thanks Rob Foddering who drew the pictures and Dr Kate Petheram who provided useful comments on the manuscript.

References

Footnotes

  • Competing interests None.

  • Provenance and peer review Commissioned; internally peer reviewed.

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