Up to 10% of patients seen by family practitioners present with neurologic symptoms and pose neurologic questions to their physicians. Only 16% of the 45 million Americans who visit a physician for a chief complaint referable to the nervous system are ever evaluated by neurologists. Clearly, primary care physicians are routinely called upon to evaluate and manage patients with neurologic disease. Practicing physicians require a firm understanding of the general principles of clinical neurology.
The most suitable setting in which to lay the foundation for that understanding is in a neurology clerkship in the clinical phase of medical school. We view the third year medical school neurology clerkship teaching as a cumulative knowledge and continuum, beginning with the second year Neuroscience Course and fourth year neurology electives to build expected core knowledge and skills in neurology.
The Neurology Clerkship is a four-week introduction to Clinical Neurology taken during the third year of medical school. It has been designed to provide a broad experience in neurology, with ambulatory and outpatient rotations and diverse patient problems from typical complaints seen in primary care to tertiary-level, refractory neurologic diseases. Also emphasized are the basic tools of neurologic diagnosis; the neurologic history and examination. The clerkship rotation sites include; USA Neurology outpatient clinic, USA Medical Center, USA Pediatric-Neurology clinic and USA C&W Hospital. Students develop their clinical skills by actively participating in patient evaluations and learn an organized and methodical approach. Students also learn to incorporate neurologic studies to help confirm their diagnoses, including neuroimaging (MRI, CT) and neurophysiologic studies (EEG, EMG and NCV).
The goal of the neurology clerkship is to provide students with the fundamental skills required by all physicians to recognize, diagnose, and formulate an initial treatment plan for patients with common neurologic disorders. As such, a principal goal of the clerkship is to help students refine skills in taking a neurologic history and performing a thorough neurologic examination, and to demonstrate and apply national standard of the principles and skills underlying the recognition and management of the neurologic diseases a general medical practitioner is likely to encounter in practice.
1. (Compc1) PATIENT CARE; to achieve and demonstrate the following:
a) obtain an accurate neurologic history, and elicit neurologic complaints
b) perform detailed neurologic examination, and distinguish normal from abnormal findings
c) localize the likely site or sites in the nervous system where a lesion could produce a patient’s symptoms and signs
d) formulate a differential diagnosis based on lesion localization, time course, and relevant historical and demographic features
e) make informed decision about appropriate diagnostic studies, explain and formulate required treatment based on scientific evidence, clinical judgment and patient preferences
f) assess the outcome, and adverse effects of therapies based on patient feedback, validated outcome measurement tools and clinical judgment
g) recognize situations in which it is appropriate to request neurologic consultation.
2. (Compc2) MEDICAL KNOWLEDGE (Cognitive); to impart and reinforce the following:
a) recognize symptoms that may signify neurologic disease (including disturbances of consciousness, cognition, language, vision, hearing, equilibrium, motor function, somatic sensation, and autonomic function)
b) demonstrate awareness of the use and interpretation of common tests used in diagnosing neurologic disease
c) apply the principles underlying a systematic approach to the management of common neurologic diseases (including the recognition and management of situations that are potential emergencies)
d) integrate basic science information (neurophysiology, neuroanatomy, neuropharmacology, and neuropathology) to clinical correlates.
e) describe key aspect of brain, spinal cord, peripheral nerves and muscle diseases clinical, pharmacologic, anatomical, pathology, causes, prognosis and management
f) identify normal and abnormal neuroimaging (CT, MRI), CSF and common diagnostic studies utilized in clinical neurology
3. (Compc3) INTERPERSONAL and COMMUNICATION SKILLS (Psychomotor);to build and reinforce the following:
a) the ability to take a complete and reliable neurologic history [see Appendix 1]
b) the ability to perform a focused and reliable neurologic examination [see Appendix 2]
c) the ability to examine patients with altered level of consciousness or abnormal mental status [see Appendix 3]
d) articulate a clear, concise, and thorough oral presentation of a patient’s history and examination
e) prepare a clear, concise, and thorough written presentation of a patient’s history and examination
f) [Ideally] the ability to perform a lumbar puncture
g) the ability to communicate with consultants, primary care providers and other members of the team.
h) the ability to communicate with the family caregivers of non-verbal patients
4. (Compc4) PROFESSIONALISM (Attitude); to demonstrate and employ the following:
a) treat patients with compassion and respect their privacy and personal dignity at all times
b) exhibit honesty and act with integrity in all patient, collegial, and professional interactions
c) demonstrate an understanding of the roles of other health care professionals and the means of collaboration with individuals providing medical care or promoting health
d) demonstrate an understanding of the need to ameliorate the suffering of patients, including but not limited to the relief of pain, and the knowledge of the means to continue to care for dying patients when disease-specific treatment is no longer useful or available.
e) show courtesy, honesty and respectfulness to all faculty, residents, fellow students and staff associated with the delivery, and all other matters associated with the clerkship.
5. (Compc5) PRACTICE BASED LEARNING AND IMPROVEMENT; to achieve and utilize the following:
a) perform literature searches on a specific topic to make evidence based decision
b) utilize the recommended learning resources of the clerkship, and course material, with modifications based on personal strengths and weakness
c) participate in team-based learning exercises and self-directed learning activities
d) display motivation to learn , and respond effectively to constructive criticism received from faculty and residents, and apply those toward improvement of patient care
e) display the desire and demonstrate scholarly achievements (e.g. good grades on the NBME, Clinical Skills Examination and faculty evaluation)
f) review and interpret the medical literature (including electronic databases) pertinent to specific issues of patient care.
6. (Compc6) SYSTEM-BASED PRACTICE; to locate and utilize the following;
a) identify multiple resources within the health care system to optimize delivery of patients care with acute and chronic neurological diseases
b) apply and relate cost-effective health care delivery to patients with chronic and debilitating neurological disorders
c) recognize and implement the involvement of multiple health care professionals, and organizations for patients and family support
d) establish collaborative approach, learn how to generate succinct, accurate and effective reports and create consultative communications with other physicians.
The students are required to, and given the opportunity to evaluate inpatients and outpatients adult and pediatric neurology cases, with more emphasis on adult neurology. They are required to obtain accurate and comprehensive medical history, perform complete neurological examination, present and discuss the case with the faculty, review and interpret diagnostic studies and formulate differential diagnosis and therapeutic plan. Then the faculty provides a thorough feedback, and monitors student experience and modifies it as necessary to ensure that the objectives of the clinical education program will be met. The faculty defines the types of patients and clinical conditions that students must encounter the appropriate clinical setting of the educational experiences, and the expected level of student responsibility.
Additionally, the faculty assures that students have acquired and can demonstrate on direct observation the Core clinical Skills, behaviors, and attitudes that have been specified in the clerkship educational objectives, specifically designed to assess students’ skills in problem solving, clinical reasoning and communication.
Students are required to keep a patient’s case log throughout the 4 weeks clerkship course and should see and examine patients with;
In addition, students should see and/or assist in performance and interpretation of neurologic procedures, including:
All attending physicians and residents are expected to provide:
Instructional strategy to enhance active learning, critical thinking and independent study to foster the skills necessary for lifelong learning are implemented. Students receive explicit experiences in using these skills, and evaluation of and feedback on their performance.
We adopt an interdisciplinary approach to integrate the basic biomedical science throughout the entire clerkship rotation thru logic interpretation of the clinical scenario, in the context of correlation with basic neuroscience and its application to human health and neurological diseases.
The educational sessions include:
a) Interactive sessions and formal educational activities
Case based discussion and presentations, videos, questions and answers. The emphases are on learning general principles and a systematic approach to patients with common neurological disorders, and illustrate essential concepts or required urgent management. Particularly noteworthy neurologic topics that are emphasized include; The neurological history and examination, principles of neurologic localization, laboratory studies and neuroimaging, confusional state and coma, dementia, headache and facial pain, neuro-ophthalmology, disorders of equilibrium, motor and sensory disorders, movement disorders, seizures and syncope, stroke, multiple sclerosis, CNS infectious diseases, neurological emergencies, spinal cord compression.
b) Team-based learning
The department of neurology adopted an instructional strategy of learning and critical thinking by shifting the instructional focus from knowledge transmission to knowledge application to enhance professional competencies that cannot be achieved through lecture- based instruction. This strategy is integrated tightly with a course’s design, alongside other learning activities.
Students are provided with reading assignments based on their learning needs, list of learning objectives and sets of questions prior to each TBL session. Students are required to answer the questions individually (individual readiness assurance test- iRAT), then they retake the exact same test again as a team (gRAT), coming to consensus on each question. Students receive immediate feedback on the team test afterwards, which can be a short, specific lecture to enable the instructor to clarify any misperceptions that become apparent during the team test.
c) Independent Self-study
Students given reading assignment with objectives. Self assessment quiz provided. The students are provided with printed material and syllabi, and provided with clerkship web page and electronic database for educational resources and continuous learning including; online videos, clips and textbooks (Clinical Neurology, 8e, David A. Greenberg, Michael J. Aminof, Roger P. Simon), Adams and Victors’ Principles of Neurology (Ropper and Samuels, eds) and a list of electronic educational resources on the Neurology Clerkship website.
d) The students are required to attend and interact with
The following educational resources are provided electronically and can be accessed online free of charge through the University of South Alabama Biomedical Library website, and the neurology clerkship web site (http://www.usahealthsystem.com/neuroeducation). If you are off-campus you will need your J-number to access these resources.
Clerkship designated textbook
It is very important that students read about their patients' disorders to reinforce their knowledge. The following are excellent references:
Clerkship required readings
Clerkship Additional Suggested Reading
Clerkship required videos viewing
Helpful Online Resources
We view evaluation and feed back to students as a very important part of the rotation. We utilize electronic online evaluation system (New Innovations) to assure speed, ease of distribution, automatic tracking and the ability to integrate and network with the administrators. These evaluations are readily available for the students to provide feedback and assessment opportunity.
Electronic evaluation form, inclusive of all clerkship attributes completed by a faculty member, or chief resident who observed and mentored the student directly during rotation, Narrative comments written by the evaluators are an important part of the process to provide feedback and justify the final recommended grade.
The National Board of Medicine Examiners (NBME) is utilized to measure the cognitive knowledge of medical students at the end of each clerkship block, and to provide the school with useful performance data that can be compared to a large, representative group of test takers at the same stage of medical educational training. The details of final grades are posted electronically on E*Value and are accessible to the medical students individually.
Grading Components Details
The clerkship coordinator and in conjunction with the clerkship director completes the grading process and submit the grades to the Office of Students Affairs in timely manner. The following grading process is implemented:
Clerkship, faculty and residents evaluation by the students is an important tool to strengthen medical teaching and evaluate our department teaching performance. The students receive an electronic request for clerkship, faculty and residents evaluation. The evaluations are completely anonymous; hence neither clerkship director, faculty nor residents will know which student submits a specific evaluation.
Student’s comments, suggestions and concern are addressed in a constructive way towards improvements for the clerkship. Fundamental changes in clerkship policy are implemented during the next academic year.
A. Develop the skills to perform the Neurologic Examination (as an integral component of the general medical examination)
B. Recognize localization - general principles differentiating lesions at the following levels
C. Develop proficiency and demonstrate a symptoms complex systematic approach to the evaluation and differential diagnosis of patients who present with:
D. Develop and demonstrate basic competencies in dealing with neurological emergencies, and proficiency in evaluating and managing common neurologic conditions (either because they are important prototypes, or because they are potentially life-threatening):
a) Increased intracranial pressure
b) Toxic-metabolic encephalopathy
c) Subarachnoid hemorrhage
e) Status epilepticus
f) Acute stroke (ischemic or hemorrhagic)
g) Spinal cord or cauda equina compression
h) Head trauma
i) Acute respiratory distress due to neuromuscular disease (e.g., myasthenic crisis or acute inflammatory demyelinating polyradiculoneuropathy)
j) Temporal arteritis
Part A: Content Organized by Common Neurological Symptoms
The student should demonstrate a systematic approach to the evaluation and differential diagnosis of patients with the following complaints:
Part B: Content Organized by Major Categories of Neurological Disease
The student should demonstrate knowledge of the following major diagnoses, being able to discuss salient diagnostic criteria (to ensure the diagnosis is correct), pathophysiology, symptoms, initial steps in management, and prognosis.
Part C: Content Organized by Neurological Organ Systems
The student should demonstrate knowledge of the major diagnoses by the following neurologic systems, including presentation of disorders, pathophysiology, formulation of appropriate differential diagnoses, a rational approach to initial evaluation, first steps in treatment, and prognosis.
M. Cerebrovascular disease
N. Demyelinating disease
O. Head trauma
P. Dizziness and disorder of hearing
Q. Disorders of higher cognitive function
R. Assessment of the comatose patient
S. Describe the diagnosis and management of increased intracranial pressure (ICP)
T. Headaches and facial pain
U. Neck and back pain
V. Brain tumors
W. Neurologic infectious disease
2. HIV and the nervous system
b) Discuss opportunistic CNS infections associated with HIV infection
X. Spinal cord disorders
a) Unilateral UMN findings with ipsilateral decreased joint position sense and contralateral loss of pain and temperature sensation.
b) Dissociated sensory loss with weakness and areflexia in the arms.
All medical students should be able to perform the following parts of the neurologic examination.
A. Mental Status
B. Cranial Nerves
C. Motor Function
All medical students should be able to perform a brief, screening neurologic examination that is sufficient to detect significant neurologic disease even in patients with no neurologic complaints. Although the exact format of such a screening examination may vary, it should contain at least some assessment of mental status, cranial nerves, gait, coordination, strength, reflexes, and sensation. One example of a screening examination is given here.
A. Mental status (level of alertness, appropriateness of responses, orientation to date and place)
B. Cranial nerves
C. Motor function
E. Sensation (one modality at toes-can be light touch, pain/temperature, or proprioception)
Note: If there is a reason to suspect neurologic disease based on the patient’s history or the results of any components of the screening examination, a more complete neurologic examination may be necessary.
A. Mental Status
B. Cranial Nerves
C. Motor Function
E. Sensation (to noxious stimuli)
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