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Introducing neurological examination for medical undergraduates—how I do it
  1. Charles Mark Wiles1,2
  1. 1School of Medicine, Institute of Psychological Medicine and Clinical Neurosciences, Cardiff University, London, UK
  2. 2Kings College, London, UK
  1. Correspondence to Professor Charles Mark Wiles, Department of Neurology, University Hospital of Wales, C2-B2 Link, Heath Park, Cardiff CF14 4XX, UK;wiles{at}cardiff.ac.uk

Abstract

Neurological examination (NE) is a key part of practice for many doctors. UK students learn NE from a variety of specialty tutors and often find it difficult. This article suggests one way of introducing NE interactively with students in their first clinical year supplementary to clerking patients. The content presupposes the author's choices about core elements and techniques of NE largely in the absence of explicit evidence. Arguably there needs to be greater consensus over a core NE, appropriate to modern practice, to provide more explicit guidance for medical schools.

  • Neurological examination
  • Medical undergraduate
  • Curriculum
  • Medical education
  • Neurology

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Background

Difficulty with neurological examination (NE), not a new phenomenon,1 is cited as one component of ‘neurophobia’.2 Students refer to inconsistency in the elements and techniques taught, indifferent teaching and poor integration with basic neurosciences.3–5 General aspects of undergraduate clinical neurology learning have recently been reviewed6 and the focus here is on learning NE.

The graduating UK doctor is expected by the licensing authority to be able to perform a full (but unspecified) physical and mental state examination, interpret the findings and synthesise them to make a diagnosis.7 The reason for including NE skills is that potentially serious and acutely presenting disorders of the nervous system (DNS) such as loss of consciousness and seizure, coma, head injury, headache, dementia, stroke, acute headache and other acute onset focal disorders including visual disturbance are common in primary and secondary care. Such disorders are emphasised in the Foundation Curriculum8 and, to varying extents, in numerous GMC approved9 specialty training programmes. However, still not all students in UK medical schools have a clinical neurology attachment. Thus, in academic year 2011–12, 26 out of 29 medical schools had attachments for all students of less than 1–5 full time equivalent weeks (median 3) (CM Wiles, PG Bain personal communication). Attachments of four10 or five11 weeks have been recommended in other jurisdictions.

UK students can learn about DNS in many settings including General Practice, Child Health, General Medicine, Care of the Elderly, Accident and Emergency, Psychiatry or on problem based learning activities and Clinical Neurology. However, while repeated exposure to DNS in different contexts has advantages there is an obvious risk of confusion for students regarding the content and techniques of NE when taught by unguided tutors from multiple specialties. Although many texts set out versions of NE for students no authoritative guidance on core learning outcomes to be achieved exists, including in the Association of British Neurologists’ document on undergraduate neurology.12 My personal view is that students need to start acquiring a specified core of NE knowledge and skills early in clinical training always in the context of important clinical problems; that neurologists are well placed as a specialty group to communicate an overall NE strategy to other specialties in their medical school; and that students should be encouraged to see learning NE as an iterative process to be refined over several years and not a one-off learning event defined by a particular assessment.

A scheme for introducing neurological examination

Students often struggle to link the patient's history, the localisation of the clinical problem and the relevant NE. Although guided tutoring of a small group of students around a patient has been the traditional approach for teaching NE, many issues including staff and patient availability, student numbers and curricular style and complexity make this increasingly hard to deliver systematically. Yet effective independent self-directed learning requires a threshold of confidence about NE which many students appear to lack. Experience in Cardiff where, until 2008, the clinical neurological attachment was very brief, and more recently at Kings College London with its longer attachment, suggests that students can find it helpful to have some interactive sessions linking basic neuroanatomy, case histories, NE and neurological signs through video clip and simulation. Such sessions, without a patient present, allow systematic introduction of core skills, and practice in clinical reasoning and communicating conclusions. A major aim is to promote more confidence and understanding when examining a patient.

The sessions

We examine patients for different reasons (box 1) necessitating changes of emphasis and detail in specialist practice but the undergraduate student initially needs a core system to build on.

Box 1
  • To explain symptoms, assist localisation and diagnosis, and exclude abnormality

  • To demonstrate understanding and relevance to the patient

  • To evaluate function (eg, consciousness, swallowing, walking)

  • To evaluate change (eg, Glasgow coma scale, strength)

  • To seek avenues of treatment (eg, spasticity, weakness)

It helps for staff to have an agreed underpinning NE document: the one evolved in Cardiff is given in the online supplementary material 1. The document should be seen only as a point of departure for a core NE which requires much wider consensus appropriate to UK training: it does not include paediatric neurodevelopmental assessment or the psychiatric mental state examination. With this document as my framework, I have 5×60–75 min sessions for up to 20 students spread through their 12 week joint Neurology/Psychiatry / Ophthalmology block in year 3 at Kings College London. The areas of NE and illustrative clinical conditions covered are summarised in the online supplementary material 2.

For a neurologist to deliver 5–6 h of contact time to groups of 20 or less students is a substantial ask in many medical schools. Is it the best use of resource? Who should do it? Could peer teaching help?13 Perhaps a starting point is for a group of UK practitioners and educators to develop a consensus on a core undergraduate NE.14 This could form a basis for recommended learning outcomes to Medical Schools. An agreed common approach to core NE may be more open to multispecialty endorsement, systematic assessment, audit and research. In addition, it might help to reduce ‘neurophobia’15 ,16 and, more importantly, improve outcomes for patients with DNS.

Acknowledgments

Thanks to Dr TAT Hughes, Dr F Schon and Professor L Ridsdale for their helpful comments.

References

Supplementary materials

  • Supplementary Data

    This web only file has been produced by the BMJ Publishing Group from an electronic file supplied by the author(s) and has not been edited for content.

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Footnotes

  • Competing interests None.

  • Provenance and peer review Not commissioned; externally peer reviewed.

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