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Undergraduate neurology in the 21st Century and the bedside tradition
  1. Mark Manford
  1. Correspondence to Dr Mark Manford, Department of Neurology, Addenbrooke's Hospital, Hills Rd, Cambridge CB20QQ, UK; mark.manford{at}me.com

Abstract

Neurology teaching highlights clinical skill and is appealing to students but after they qualify the subject has a notorious reputation. Changes in clinical practice with fewer inpatients provide challenges to traditional teaching, but there are nevertheless opportunities for combining creative teaching methods with modern technology to provide a rich, enduring and relevant learning experience that can create a generation of clinicians not intimidated by a tendon hammer.

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If you think back to your training, I imagine that what you remember best are the clinical cases. Neurology does this really well and consequently is popular as an undergraduate attachment. The traditional style of teaching emphasises clinical skills, links directly to undergraduate neuroscience and is based around the bedside. It can lead to Damascene moments of realisation that are a joy to both student and teacher. Neurologists extract science from human stories and from clinical examination. Listening is key; how often have you changed a diagnosis because the patient described their symptoms as tingling rather than numbness or you have rediagnosed confusion as a dysphasic stroke.

We all like listening to people's stories. The personification of a learning principle is a standard technique to bring a subconsciously human immediacy to a lesson: from the Teletubbies to the portrayal of God as a wise man with a beard. Combine that with a specialty in which history taking and examination are a craft where practitioners use their own skills—with limited recourse to investigations—and you have both the joy to the initiated and the challenge to the novice, that is, clinical neurology. When students are with us, we can convey this excitement to many of them. Yet as they drift through other areas of the curriculum, that exhilaration and intuition are lost and neurology gains the reputation of being complex and abstruse.

One challenge facing neurological teachers is how to maintain that wonder in the stories patients tell in the face of fewer patients on the ward, and how to combine our increasingly pressured working environment with delivering high-quality teaching. Students gain from being in outpatients but they must not be passive observers.1 My technique is to write the notes while the student takes the history of the presenting complaint, or I take the history and they examine one part of the nervous system. Students can be asked to comment on communication skills. I have found them to be particularly insightful after difficult consultations in providing perspectives on patients’ behaviours. The 1-min teacher2 is well worth a try.

A student cannot be expected personally to see the full range of clinical signs. Seeing an internuclear ophthalmoplegia on the web is not the same as eliciting it yourself, but is much better than in the days before e-learning, when you would have been lucky to see it before becoming a practising clinician. Many medical schools are developing their own video library of signs. As so often, the wheel is reinvented over and over and this is an opportunity for collaboration to everyone's advantage.

The other challenge is to debunk the myth of neurological complexity. No neurological pathway is anywhere near as difficult to understand as the Nernst equation. The truth is that the day-to-day principles by which neurologists work are quite simple. Are the reflexes brisk or reduced? Is the visual loss monocular or binocular? If it is monocular, is there a relative afferent pupillary defect? This is what we need to convey. If anything, inpatient neurology emphasises the complex and difficult. We want our students to gain a basic qualification across the range of neurological emergencies and commoner conditions and not a higher qualification in rarities. Lambert–Eaton myasthenic syndrome is a wonderful clinical expression of basic science but does every new doctor need to be able to diagnose it?

‘Less is more’ is a lesson forever taught to educators and one that I can identify with—most enthusiastic teachers deliver too much content and pay little attention to learning styles. Some can acquire information from a diagram; others prefer to hear from an ‘expert’. Some like lectures, some like books, some like just raw facts (always worries me), others like principles and explanations (much better). Educational resources need to be diverse.

These varied needs require the engagement of students in developing their own learning materials. Students for whom web-based learning is second nature rather than innovative make use of resources in ways that their teachers (we old fogies) may not understand. If we are to develop curricula in a way that is relevant, students need to be involved in their design. This does not mean that they determine their content, since without the knowledge they have yet to acquire, they cannot fully understand the priorities.

We may love our topic but students too often learn only to pass an exam—assessment drives learning. Tell them it is for the exam and they will turn up, otherwise they will not. This is undoubtedly true and we see many instances in my own clinical school, but it is depressingly narrow. Perhaps the answer is to lure students with a promise of exam relevance and then to provide an experience, which is exciting and stimulating, full of stories and reinforced by digital media, engendering a passion for learning for its own sake, or am I being naïve? I believe neurology can remain an exemplar specialty to do this, but we have to move with the times.

References

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Footnotes

  • Competing interests None.

  • Provenance and peer review Commissioned; externally peer reviewed.

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