As the new academic year begins, it is appropriate to provide the faculty with a guide to the structure and requirements of the third-year medical student clerkship in neurology. There are some changes that have been made to the clerkship, and it is anticipated that refinements will continue to be made throughout the year. As always, faculty participation and input are the critical factors in making this a successful educational experience for our students.
Primary Goals of the 3rd Year Neurology Clerkship
- Gain competence in taking a neurologic history and performing a neurologic exam, and use them to aid in localization and diagnosis of neurologic disease
- Develop knowledge, attitudes, and skills necessary to assess, diagnose, and refer patients presenting in the primary care setting with neurologic complaints
- Have the opportunity to explore the field of neurology as a potential career path through exposure to a variety of complaints and diagnoses through patient encounters and case-based didactics
At the completion of the third-year clerkship, the student should have acquired the ability to:
- Recognize common neurologic disease presentations.
- Perform a screening neurologic history and examination.
- Localize a lession based on clinical information.
- Generate a differential diagnosis for common neurologic complaints.
- Develop a practical approach to the evaluation and management of common neurologic complaints.
- Appropriately order and interpret information from common neurologic diagnostic evaluation, e.g. neuroimaging, lumbar puncture.
- Recognize and appropriately respond to neurologic emergencies.
- Be Familiar with ethical and psychosocial problems encountered in the care of neurologically ill patients.
Structure and Required Activities
Students spend four weeks on their clinical neurology rotation at one of five sites: Ronald Reagan University Medical Center (Westwood), West Los Angeles VA, Olive View-UCLA Medical Center, Cedars-Sinai Medical Center or Harbor-UCLA Medical Center. During that time, they are expected to participate fully as a member of their assigned team in both inpatient and outpatient settings, performing neurologic examinations and assessments on patients, presenting the patients to their residents and attendings, discussing diagnosis and management principles, and writing daily progress notes.
In addition, students enrich their participation in other aspects of clinical neurology by attending site specific lectures and seminars, performing two nights of long call and two weekend days on service over the course of the four week rotation. Didactics include case-based small group discussions interspersed through the clerkship. The NBME Neurology Shelf Exam must be completed at the end of the rotation.
For UCLA Neurology attendings working with third-year medical students
Our student satisfaction ratings of the clerkship have risen noticeably, more students are entering neurology residencies, and now roughly 805 of students report having been observed by an attending performing the neurological exam (up from 55% last year). Here are some tips for this coming academic year 2006-2007:
- Raise the bar: Students rise to the level of their expectations and according to our evaluations, they expect you to expect more of them. This includes pre-rounding, presenting patient information, writing notes and orders, and giving talks.
- Impatient attendings, try some of these standard techniques on rounds sometime:
- Observe the full neurological exam done by the student at least once
- Teach how to incorporate the neurological exam into a general physical. The HEENT exam provides most information about cranial nerves, sensory exam showa us the skin/edema, etc. to make it more applicable to students pursuing other specialties.
- Demonstrate the physical exam and model respect for the patient (close curtains or doors, keep the patient's body covered, let the patient know what you are doing, etc.)
- Doing is better than watching: Send the students to the ER or ward first to see the patients if possible. Studies show that the patients identify with the early care giver and students hence feel more responsibility for the patient.
- Fun techniques for inpatient teaching:
- Have you or a resident pretend to be a "new" patient with simulated neurological findings.
- If the students get good at above, have them pretend to be a patient
- "Ministry of Silly Walks":Try out a new neurologic gait on the way to radiology, like parkinsonian, ataxic, trendelenberg, etc.
- "Tag team neuro exam": Have each student specialize in a different portion of the neurological exam for a set period of time, like a week. So on every patient that morning during rounds, the student would examine the cranial nerves while his partner does strength testing. Next week, he would examine the reflexes on all the patients, etc.
- "Focused daily ward rounds": On any given day, decide to demonstrate how to do the ankle jerk, babinski, visual fields, etc on all the ward patients.
- "Cold patient exercise": Have the student perform the neurologic exam on rounds on someone else's patient admitted overnight. This is good at simulating "real life."
(Above adapted by Dr. William Campbell, "Teaching the Neurologic Examination in the 21st Century" from Unformed Services University of Health Sciences, Bethesda, MD)
- Outpatient teaching techniques:
- Answer a pertinent question for your patient using PubMed, or Cochrane Database.
- Use website to demonstrate your ideas. Try metasite for links to neuro sites on any number of topics. Also, for a good simulation of eye movement abnormalities check richmondeye.com
- Show them videos of common patient problems if available
- Ask them what they have in their PDA patients log already (students required by medical school to log their patients), and what diagnoses they haven't seen yet.
- Have your students write a "Best Bet" analysis to answer a three-part question encountered in clinic and bring it in next week.
Example: "In patients with [relapsing-remitting multiple sclerosis] are [high dose interferons or low-dose interferons] better at [relapse rate reduction]? All UCLA students are trained in this form of analysis and it takes 2-3 hours to compile. This can also be used for the inpatient services. Check out bestbets.org for example.