The neurology clerkship is a required or core rotation in over 90% of U.S. medical schools. Although most students rotating through the Department of Neurology will not become neurologists, this is an important rotation no matter what specialty is eventually chosen as a career choice. Neurological problems are common, and many patients will initially present to other providers. Unfortunately, the evidence indicates that many non-neurologists are uncomfortable with the evaluation and management of neurological conditions. To deliver optimal care to these patient, it is clear that future physicians must have a strong foundation in neurology, and the neurology rotation will allow for the acquisition of knowledge and experience in this very important area.
The neurology rotation is also important in residency selection. "Grades in required clerkships" are an important factor in the residency selection process for all specialties, and therefore excellent performance in the neurology rotation can help you reach your professional goals. For those students seeking to pursue a career in neurology, the neurology rotation grade takes on even more importance. In the 2016 NRMP survey of neurology residency program directors, 77% cited "grades in clerkship in desired specialty" as an important factor in making interview decisions. It received a mean importance rating of 4.4 on a scale of 1 (not at all important) to 5 (very important). The only factor rated more important was "any failed attempt in USMLE/COMLEX."
Given the importance of the neurology rotation in the residency selection process, I am often asked for advice on how medical students can make a favorable impression on attending physicians and residents. Below are some very specific recommendations for success.
Adjust Your Attitude
Do you suffer from neurophobia? Defined by Jozefowicz in 1994, neurophobia is a "fear of the neural sciences and clinical neurology." Studies of medical students across the world have shown that neurophobia is common, affecting up to 50% of students at some point in their medical education. Although the reasons for neurophobia are varied, most students report one or more of the following:
Trouble with neuroanatomy
Trouble with clinical examination
Trouble with neuroscience
Complexity of the subject
Too many rare diagnoses
As a result of prior experiences, students may enter the rotation in a heightened state of stress, doubtful of their abilities to overcome past struggles. This is precisely the type of mindset that is counterproductive to having a successful neurology rotation experience.
If you're having any doubts or fears, I urge you to take stock of your emotions and do whatever is needed to adjust your attitude. Your willingness to embrace this new rotation will be key to maximizing the most of your learning opportunities.
Review Clinical Neuroanatomy
If you're like most students, your last significant exposure to neurology probably took place 1-2 years earlier during the basic science years of medical school. I'm sure you remember learning about the principles of neurological localization in your neuroanatomy class.
Now, it's time for a refresher course. Start with some excellent video clips. In one study of students using video clips, 98% reported better visualization of neurology concepts after reviewing videos. One such clip is shown below.
Gather Your Tools
To perform a comprehensive neurological exam, you will, of course, need the proper tools. These include:
Take A Superb History
Medical students who have rotated with me on the internal medicine service have repeatedly heard the words, "The money is in the history." This is true of all specialties, and neurology is certainly no exception. The neurological history is an important part of the patient's workup, and errors in history taking can lead to misdiagnosis with potentially disastrous consequences.
If your neurology rotation will entirely or largely be an inpatient-based experience, become familiar with the most common complaints you'll encounter. Most of your patients will either come to your neurology service from the emergency department or other services of the hospital (consults).
Neurological symptoms are common in the ED, accounting for approximately 5% of visits. Analysis of these visits have revealed that the most commonly encountered symptoms include headache, weakness, dizziness, back pain, and seizure disorders.
Before your neurology rotation, I recommend that you become familiar with the evaluation of these symptoms and problems. Carefully note the potentially life-threatening causes of these symptoms since a major part of your initial evaluation will be focused on assessing your patients for these conditions. An excellent review about misdiagnosis of neurological emergencies, including the reasons for misdiagnosis, was published in Emergency Medicine International several years ago.
An increasing number of neurology rotations are requiring their residents and attendings to observe the history taking of students. In conversations I've had with my colleagues in neurology, the following are some of the more common mistakes that have been noted in these observed encounters:
Failure to set the stage for a positive encounter (e.g., proper introduction, ensuring comfort and privacy, sitting down)
Failure to ask open-ended questions or moving quickly from open-ended to yes-no questions
Frequent interrupting of patients
Not asking clarifying questions (e.g., asking patients to describe what they mean by "dizziness")
Not obtaining a chronological history
Failure to ask about positive and negative localizing and differential symptoms
Letting diagnoses made by others affect your history-taking
Not inquiring about how the disease has affected all spheres of the patient's life
Poor understanding of the patient's social support and living situation
Note that your ability to take a superb history will also be impacted by the patient's condition. You'll have to seek additional sources of information for patients with impaired consciousness or attention, dementia, or seizure. Your persistence in locating family, speaking with caregivers at nursing homes and other assisted facilities, and soliciting accounts from those who have witnessed events leading to hospitalization will be crucial to completing the history. Medical students who go to these lengths to provide high quality care are quickly recognized for their commitment to excellence.
Learn How To Perform The Neurological Exam
Although you were introduced to the complete neurological exam during the physical diagnosis course, your other rotation experiences may have limited your opportunities to build upon these skills. As a result, you may enter the neurology rotation feeling uncomfortable about your abilities to perform an accurate exam. Don't worry, you're not alone. The good news is that the neurology rotation will provide you with numerous opportunities to hone your skills in this important area.
Your goals will be to develop proficiency with both the hypothesis-driven and complete neurological examination. In performing the exam, structure and sequence are important according to Dr. Rob Naismith, Neurology Clerkship Director at Washington University. Dr. Naismith has created an excellent guide for the neurological exam with a focus on "what to do," "what to say," and "what to observe" for every component of the exam.
Once you're aware of what needs to be done, then it's a matter of practice. "The neurology clerkship is the ideal time to get this practice, because you will be seeing many patients with both normal and abnormal findings," writes the American Academy of Neurology. "Abnormal findings will become more obvious with practice, and you will learn to recognize them via observing attending neurologists and residents perform the exam. Ask them to watch you examine patients, as they can then provide you with feedback on your technique and findings."
Present Cases Powerfully
Although the typical neurology case presentation lasts 5 - 10 minutes, it's always best to check with your attending or resident for their preferences. A common error is to exceed your allotted time. You'll have spent hours with the patient, gathering mountains of information. However, your attending will not want to hear this level of detail.
It'll require some judgment on your part to decide what should and shouldn't be included. A useful approach is to consider the differential diagnosis of the patient's presenting complaint or problem. Then ask yourself what information will the attending need to assess the likelihood of the conditions in your differential. Using this approach, you can ensure that your case presentation includes the pertinent positives and negatives.
When presenting the neurological exam, it's vital that you convey the information in the expected order, as follows:
After presenting the history, physical exam and other data, remember to share your thoughts about localization. Then offer a differential diagnosis based on your localization followed by a plan, including testing to establish the diagnosis and treatment.
Although neurological localization sounds daunting, the evidence indicates that students can localize well. In one study of medical student performance during the neurology clerkship, in nearly 75% of encounters, researchers found that students "were able to identically or closely localize the likely site of the lesion." This study was also enlightening because it revealed common errors made by students:
Many students had difficulty recommending proper diagnostic testing. In only 1/3 of the time were students in agreement with faculty.
Formulating a management plan was also a difficult area with students often failing to discuss issues beyond pharmacology such as education, lifestyle modifications, support group referral, and recommendations for equipment for the prevention of complications.
Your attention to these aspects of the case presentation will allow you to stand out from other students.
More tips for anesthesiology rotation success can be found in our podcast:
Advice for the Neurology Rotation
Dr. Samir Desai is the author of The Successful Match 2017 and the co-host of the Success in Medicine podcast.