TEACHING THE NEUROLOGIC EXAMINATION IN THE 21st CENTURY

William W. Campbell, MD, MSHA

Uniformed Services University of Health Sciences
Bethesda, MD

How important is it to teach the examination in an era of sophisticated neurodiagnostics?1-3 The pro-technology,
rely on the test(s), argument can be summed up in the neurosurgical aphorism: “One ___________ (fill in the
blank with MRI,CT, A/G, PEG, etc, depending on the era) is worth a roomful of neurologists.”

The anti-technology lament is also nothing new:

"There has been within recent years an interesting tendency to rely more and more on laboratory, mechanical and
other such methods...at the expense of careful clinical observation."
Sir Gordon Holmes, in a 1953 foreword to Wartenberg's Diagnostic Tests in Neurology.

The 21st century neurologist often practices "MRI negative neurology" and is asked to see patients when the
imaging studies are unrevealing, but a neurologic illness is still suspected, or when neuroimaging reveals
unexpected abnormalities. Other arguments supporting continuing to teach the neurologic examination can be
brought to bear (see Neuro-Crossfire II, this meeting). Death of the neurological examination was probably
predicted during the era of pneumoencephalography; it not only survives it is in robust use. If we conclude that the
techniques of the neurologic exam are worth continuing to teach to medical students and residents, how do we go
about the task?

WHO TO TEACH

A study was done of the influence of attending behavior on student learning of the neurologic examination during
a neurology clerkship (not published). Attendings overseeing students use different styles and approaches to
teaching the neurologic examination, some elaborate and others cursory. This study was done to determine
whether different styles of teaching the clinical neurological examination affected student performance on an end
of rotation practical evaluation of neurological examination technique.

Third year students at the Medical College of Virginia were required to perform a neurological examination on a
patient, under the observation of a neurology resident, at the end of the rotation, for a grade. Using a survey, the
entire housestaff group, all of whom had rotated with and been supervised by all of the attendings, then rated the
attendings, on the basis of their own personal experience, according to their approach to teaching the
examination into three groups: those who generally performed at least a focused examination on most patients,
frequently demonstrated abnormal exam findings and specifically made it a point to teach exam techniques, those
who did only occasional, brief examinations during the rotation and relied heavily on housestaff description of
abnormalities, and those who relied almost exclusively on housestaff and student description of exam findings,
rarely or never examined a patient in front of the rounding group, rarely or never demonstrated abnormal physical
findings, and made no effort to teach the exam.

The entire third year class of 161 students was divided into three groups and an analysis was conducted of
students' practical examination scores according to the examination teaching style of the attending who had
supervised their rotation. Neither by analysis of variance nor regression was there any demonstrable relationship
between attending attributes vis-a-vis teaching students how to perform a neurological examination and student
performance of a neurological examination at the time of subsequent formal competency evaluation. Students
taught by attendings who rarely or never demonstrated the neurological examination performed just as well on
formal testing as did students supervised by attendings who emphasized the importance of the examination,
demonstrated it frequently, observed students performing the exam, and made a deliberate effort to teach exam
techniques. There was no statistically significant difference in student's grades on their practical neurological
examination evaluation related to their supervising attending's attempts to teach examination skills. The
conclusion suggested by this study is that the attending appears not to be a particularly important source of
learning about the neurological examination for medical students. Time may be better spent teaching and honing
the examination skills of the residents, leaving the teaching of examination technique to the students primarily to
the residents. However, a 2003 study of internal medicine residents found that almost one third spent no time
whatsoever at the bedside teaching physical examination to students.4

HOW TO TEACH

Finding time to teach anything has never been easy, and seems to be getting harder. In Time to Heal: American
Medical Education from the Turn of the Century to the Era of Managed Care, K. M. Ludmerer describes the
current state of medical education and how the time constraints imposed by managed care, rampant medical
commercialism and other factors are compromising medical education. He calls for reform of a broken system,
but it is not likely changes will be forthcoming in the near future. Performing the juggling act between teaching and
patient care has always been difficult to do, but it is not impossible.

Regarding clinical teaching, there are two fundamental approaches to teaching the examination: active and
passive. In using a passive approach to teaching, the student is left to learn the examination largely on their own,
through trial and error, by reading textbooks, or from other students. This approach is generally not satisfactory
and does not lead to very well developed examination skills. Active efforts to teach the examination can be done
in at least three ways: by demonstration, by simulation, and by observation of the trainee.

INCORPORATING THE GENERAL PHYSICAL EXAMINATION INTO THE NEUROLOGIC EXAMINATION

Medical students frequently suffer from "neurophobia" and find neurology in general intimidating and the
neurologic exam mystifying, arcane, complex, and time-consuming. Most medical students will not become
neurologists. Especially for those going into primary care specialities, a frequent refrain is a request to be taught
how to incorporate the neurologic examination into the general physical. Some have the idea that the neurologic
exam is a separate process from the general physical, and they often omit it for lack of time. Some
nonneurologists will actually schedule a separate appointment for a neurologic exam. I encourage students,
rather than thinking about how to incorporate the neurological exam into the general physical, to turn this concept
on its ear and think about incorporating the general physical into the neurological exam. Any neurological
examination, even a cursory one, provides an opportunity to accomplish much of the general exam. An HEENT
exam is a natural byproduct of an evaluation of the cranial nerves. After listening for carotid bruits, it requires very
little additional effort to palpate the neck for masses and thyromegaly. A good motor and reflex exam, and an
evaluation of gait and station provide a great deal of information about the patient's orthopedic condition. It is
difficult to miss a bad knee, shoulder or hip during the process. Testing sensation and plantar responses provides
an opportunity to coincidentally look at the skin and nails and feel the peripheral pulses. At the end of a good
neurological exam, one only has to listen to the heart and lungs and palpate the abdomen to have also done a
fairly complete general physical examination.

DEMONSTRATION TEACHING

In demonstration teaching, trainees watch the mentor examine patients. The student may be watching the
resident or the attending, or the resident may be watching the attending. A great deal can be taught using this
method, particularly if the examiner is able to discuss and explain what he or she is doing and why. Some
attending are better than others at giving a running narrative while simultaneously examining and interacting with
the patient. Lack of this narrative makes demonstration teaching much less effective. One of my colleagues
trained under Dr. E. F. Gonyea, and learned how to do a neurologic examination largely by watching Dr. Gonyea
do an extensive examination on patient after patient. Although trainees sometime complain that this technique is
boring, they will often later admit a great deal was learned. An effective approach is to rely primarily on
demonstration for the first several days to a week (assuming a four-week rotation), making an active effort to
teach examination technique, and then for the remainder of the rotation to rely on a combination of simulation and
observation.

Demonstration teaching must be done at the bedside. There has been a long-running debate on the pros and
cons of bedside teaching. There has been an increasing tendency in recent years to gather in a conference room
and "doctor the chart" and a lessening tendency to make bedside teaching rounds. This is influenced by certain
externalities is over which we have little control, such as the documentation requirements for reimbursement, the
short and hectic nature of an inpatient stay, as well as privacy concerns. However, the primary driver determining
the approach taken is attitude and the willingness to expend effort. It is more physically, emotionally and
intellectually challenging to make bedside rounds. It is simply easier to sit in a conference room with the trainees
and the charts, or the computer (and the doughnuts).5 Much can be lost because of this.
I have certain rules for bedside presentations and teaching, and the students must be told before hand what the
rules of engagement are. First and foremost is that the patient must be involved in the process and interacted
with, not made to feel like an object. Euphemisms must be used for any terms that may cause concern for the
patient, and certain terms, such as cancer, AIDS, MS and ALS, are forbidden at the bedside. The speaker must
pay careful attention to what they are about to say. Lastly, it is impossible to tell what part of the conversation the
patient may misconstrue or misinterpret, so it is the duty of the student to visit the patient after rounds to answer
any questions and allay any concerns that may have arisen during the bedside visit.

SIMULATION

Another approach is to use simulated patients. Here, the trainee examines a person who is not an actual patient,
under the watchful eye of the teacher. A formal simulated patient, the type used in simulation centers, is a lay
person trained to give a history of a particular condition, and sometimes to simulate physical exam findings, such
as a Babinski sign. In simulation centers, trainees take a history and do an examination on a simulated patient
while being observed, usually by remote video, by one or more evaluators. The sophistication of modern
simulation centers is impressive. Some of these professional simulated patients are quite skillful, but they are in
short supply, and time in simulation centers is difficult to come by.

A more practical approach for most purposes is to do an informal simulation using another member of the ward or
clinic team. The best individual to act as the simulated patient, bar none, is the attending (the neurologist as
patient). The attending can posit a clinical scenario, such as "I am a 70-year-old right handed man brought by his
family to the emergency room because of difficulty talking" and then go on to imitate aphasia and a right
hemiparesis. Depending on the level of sophistication of the trainee, the findings could vary from subtle (e.g.,
conduction aphasia and minimal pronator drift) to gross (e.g., global aphasia and dense hemiplegia). One
approach when ward attending is to ensure that there is always a "new patient" on each rounding day, if there is
no actual new patient there is a simulated new patient. Through the course of a ward rotation, each member of
the rounding team is given the opportunity to serve as the examiner for a simulated patient. There are many
clinical conditions that can be simulated in such a fashion. Some findings that lend themselves readily to
simulation include hemiparesis, from mild to severe, facial weakness (central or peripheral, unilateral or bilateral),
sensory loss in a particular distribution, visual field deficits, an upgoing toe, extinction, neglect, aphasia, other
types of focal weakness (ulnar neuropathy, radial nerve palsy, foot drop), symmetrical proximal weakness, and
symmetrical distal weakness. It is even possible to simulate a carotid bruit.

Some of the clinical conditions that lend themselves readily to simulation include hemispheric stroke, brainstem
stroke, myasthenia gravis, polymyositis, paraparesis, quadriparesis, radiculopathy, plexopathy, focal motor
seizures, various tremors and other abnormal movements, alien hand and many others. Eye movement
abnormalities can be simulated by moving the hands. The limit is determined by one's imagination and acting
ability. The level of complexity can vary to depending upon the sophistication of the trainee. Students might be
shown relatively straightforward things such as a left hemisphere stroke or Guillain-Barré syndrome, residents
such things as internuclear ophthalmoplegia or polymyositis. Neuromuscular fellows might be challenged with
such things as a posterior interosseous neuropathy or and upper trunk brachial plexopathy. With some of these
very complex situations it is often challenging for the simulator to accurately portray the findings, but this is part of
the fun and one can be confident of the abilities of the trainee who detects errors in the simulation.

Some of the things that are very difficult to simulate include abnormal pupils and abnormal reflexes. It is actually
possible to simulate an afferent pupillary defect using a neutral density filter. The following web sites are very
useful for simulating eye movement and pupil abnormalities: cim.ucdavis.edu/eyes and
www.richmondeye.com/eyemotil.asp. One can change reflexes subtly by taking advantage of the tonic neck
reflex, turning the head ipsilaterally to exaggerate a biceps reflex and contralaterally to depress it. Otherwise it is
difficult to simulate DTR abnormalities.

A variation of this technique is for one trainee to simulate findings for another trainee, again under observation by
an instructor. A trainee who can accurately and convincingly simulate pronator drift has a good understanding of
the underlying pathophysiology. This technique assesses both the trainee who is the simulated patient as well as
the trainee who is doing the examination, and can be very efficient and productive.
THE MONTY PYTHON MINISTRY OF SILLY WALKS

An excellent method for teaching the different gait disoders is to teach trainees to simulate a particular type of
abnormal gait. Example of abnormal gaits that lend themselves readily to this sort of imitation include: hemiplegic
gait, parkinsonian gait, festination, spastic diplegia, cerebellar ataxia, sensory ataxia, foot drop (mild or severe,
unilateral or bilateral), Trendelenberg gait and marche a petit pas. Again, the trainee who accurately demonstates
a hemiplegic gait demonstrates a knowledge of such things as the pyramidal distribution of muscle innervation,
spasticity and the clinical manifestations of a corticospinal tract lesion. More advanced trainees could be asked to
imitate such things as a magnetic gait, waddling gait due to proximal weakness and the prancing gait of
Huntington disease. If the teacher has a group of trainees, all imitating a hemiplegic gait, walk toward him or her,
it is easy to pick out who has it right and who has it wrong. A good way to use the ordinarily wasted time traveling
around the hospital from place to place is to have trainees imitating various abnormal gaits along the way,
although it will draw some curious glances.

FUNDUS EXAMINATION SIMULATION

It is difficult to teach fundus examination. Many students, and even some senior housestaff in nonneurologic
specialties, such as internal medicine, are nearly incapable of evaluating the fundi. Looking at slides or textbook
photographs of abnormal fundi is useful, but does not closely simulate the the actual clinical fundoscopic
examination. A convincing simulator can be simply constructed using a single slide viewer. A piece of paper is
taped over the viewing surface, and a hole punched in the paper about the size of a pupil. Slides of fundi are
placed in the viewer and illuminated by the viewer as if one were looking at slides, but the student looks at the
slide through the "pupil" using an ophthalmoscope (the light is best left off). This technique works very well with a
small group of students, each with their own ophthalmoscope, and several viewers. The instructor places
unknown slides into the viewer, and the group tries to make a diagnosis. Conditions that are very well
demonstrated using this technique include: varying degrees of papilledema, drusen, and optic atrophy. Any type
of fundus abnormality, such as diabetic retinopathy, could be taught with the same technique. Trainees are
uniformly enthusiastic about this teaching method. Under simulation conditions, the fundi of the “patient” can be
shown with the viewer.

OBSERVATION

A great deal can be learned from watching a trainee conduct an examination on a patient or on a normal control.
A consistent finding in studies of clinical teaching has been the lack of direct observation of trainee interactions
with patients. Many have observed that clinical skills are no longer actively taught. Few students report having
been monitored while interviewing or examining more than 1 or 2 patients during their entire medical school
careers, and a surprising number graduate without having been supervised or observed while working up even
one patient. Frequent reports of serious skill deficiencies of interns and residents attest to the effect of the
abandonment of bedside, hands-on clinical teaching. Much can be learned by watching trainees actually do an
examination.6 In the course of watching many students and residents examine patients, and of being examined in
the role of simulated patient, certain common errors and omissions have become apparent. Table 1 lists some
frequent errors. It is often surprising and sometimes astounding what errors are made, e.g., stimulation of the
sclera rather than the cornea for the corneal reflex, auscultating the carotids over the belly of the sternomastoid.

OTHER TECHNIQUES FOR TEACHING THE EXAMINATION

Other techniques I have found useful include the tag team examination, exam focused rounds, the cold patient
exercise, and role reversal.

TAG TEAM NEUROLOGIC EXAMINATION

Since the examination is so complex, one effective technique is to have each student specialize in a given part of
the examination for a set period of time, such as a week. During a given week, one students does all the cranial
nerve exams, another all the motor exams, another all the reflex, sensory cerebellar and gait exams, and another
all the mental status exams. This assumes four students on a ward team for a four-week rotation. The students
then rotate the responsibility for different parts of the exam. When evaluating a new patient, the students do a
“team” examination, under the observation of the attending (or the resident).
NEUROLOGIC EXAMINATION FOCUSED DAILY WARD ROUNDS

Occasional daily rounds can be tailored to teaching specific, often problematic, aspects of the examination. On a
particular day the team makes “ankle jerk rounds,” and each student elicits the ankle jerks on every patient.
Given a decent sized inpatient service, in one rounding session the students see a range of ankle jerks from
absent to hypoactive to normal to spastic, and have the opportunity to markedly improved their technique in a
relatively short period of time. This can be combined with teaching basic neuroscience, asking the students to
describe, between patients, the pathways and neurophysiology for the ankle reflex. On another day the team may
make “toe rounds,” eliciting the plantar responses on every patient, under the observation of the mentor. Likewise
for eye movement rounds, pupil rounds, etc. The focus must remain very narrow for such an exercise, or it
becomes too time-consuming.

THE COLD PATIENT EXERCISE

A very useful exercise is to have either the student or the resident perform a 20 to 30 minute evaluation on an
unknown patient. An efficient approach is to use new patients admitted to a different student or resident, and,
rather than having a formal presentation and examination by the attending, under appropriate circumstances a
team member who does not know the patient is asked to the evaluation at the bedside under the observation of
the remainder of the team. A period of 20 minutes works fairly well, and simulates “real life” as this is about the
length of time one is allowed to evaluate a patient in the emergency-room and in many clinics. The individual
assigned to evaluate the patient takes a brief focused history and does a focused examination, then comes up
with a differential diagnosis. After the evaluator has completed the task, other team members are asked to
critique the exam that was done, particularly noting whether any important aspects were left out. This is a way to
keep the other team members engaged, as they learn quickly that this question is coming and begin to pay
careful attention. At the end of this exercise, the mentor will probably have a very good idea of what is going on
with a particular patient, but can conveniently ask a few questions or perform a few examination maneuvers as
needed. Trainees have a “love-hate” attitude toward this 20 minute, cold unknown patient drill. They find it very
useful in honing their clinical skills and in learning efficiency, but they naturally dislike being placed in the
spotlight. At the end of a rotation, it is a rare trainee not willing to admit they love it more than they hate it.

RESIDENT AS ATTENDING

Another form of cold patient drill is the role reversal exercise, which can be very elucidating. For a particular new
patient, the attending has the resident function as the attending; the students present to the resident, and the
attending acts as an observer, trying to stay in the background as much as possible. This technique works best
with senior, experienced residents. It will not be useful unless the resident has an acceptable level of clinical skill.
The resident is responsible for evaluating the patient and teaching the students during a particular new patient
encounter. Afterwards, the attending does what is necessary to clarify the situation, then critiques the residents
performance.

RESOURCES FOR TEACHING THE EXAMINATION

There are print and electronic resources available to supplement hands on clinical instruction for teaching the
exam. There is a wide range of books on the examination (Table 2), ranging from the Four-minute Neurologic
Exam (56 pages, $12.95) to DeJong’s The Neurologic examination (6th edition, 2005, 640 pages, $110.00).7-25
There are many resources available on the internet (Table 3).

References

1. Ziegler DK. Is the neurologic examination becoming obsolete? Neurology 1985; 35:559.

2. Flegel KM. Does the physical examination have a future? CMAJ 1999; 161:1117-1118.

3. Mangione S, Peitzman SJ. Physical diagnosis in the 1990s. Art or artifact? J Gen Intern Med 1996;
11(8):490-493.

4. Smith MA, Gertler T, Freeman K. Medical students' perceptions of their housestaffs' ability to teach physical
examination skills. Acad Med 2003; 78:80-83.
5. Anderson RJ, Cyran E, Schilling L, Lin CT, Albertson G, Ware L, et al. Outpatient case presentations in the
conference room versus examination room: results from two randomized controlled trials. Am J Med 2002;
113:657-662.

6. Hamdy H, Prasad K, Williams R, Salih FA. Reliability and validity of the direct observation clinical encounter
examination (DOCEE). Med Educ 2003; 37:205-212.

7. Goldberg S. The 4-Minute Neurologic Exam. Miami: MedMaster Publishing, 1999.

8. Fuller G. Neurological Examination Made Easy, 3rd ed. New York: Churchill Livingstone, 2004.

9. Lewis SL. Field Guide to the Neurologic Exam. Baltimore: Lippincott Williams & Wilkins, 2003.

10. Wolf JK. Segmental Neurology: A Guide to the Examination and Interpretation of Sensory and
Motor Function. Baltimore: University Park Press, 1981.

11. Massey EW, Pleet AB, Scherokman B. Diagnostic Tests in Neurology. New York: Elsevier, 1985.

12. DeMyer WE. Technique of the Neurological Examination, 5th ed. New York: McGraw-Hill, 2003.

13. Mayo Clinic Department of Neurology. Mayo Clinic Examinations in Neurology, 7th ed. St. Louis: Mosby,
1998.

14. Campbell WW. DeJong's The Neurologic Examination, 6th ed. Baltimore: Lippincott, Williams & Wilkins
2005.

15. DeJong RN, Haerer AF. Case taking and the neurologic examination. In: Joynt RJ, Griggs RC, eds. Baker's
Clinical Neurology on CD ROM. Baltimore: Lippincott, Williams & Wilkins, 2002.

16. Campbell WW, Pridgeon RM. Practical Primer of Clinical Neurology. Philadelphia: Lippincott Williams &
Wilkins, 2002.

17. Ross RT. How to Examine the Nervous System, 3rd ed. New York: Appleton & Lange, 1999.

18. Alpers B. Alper's and Mancall's Essentials of the Neurologic Examination. 2nd ed. FA Davis, 1981.

19. Glick T. Neurologic Skills: Examination and Diagnosis. Boston: Blackwell, 1993.

20. Bates B, Bickley LS, Hoekelman RA. Bates' Guide to Physical Examination & History Taking, 7th ed.
Philadelphia: Lippincott Williams & Wilkins, 1999.

21. DeGowin RL, LeBlond RF, Brown DD. DeGowin's Diagnostic Examination, 8th ed. New York: McGraw-Hill,
2004.

22. Gelb DJ. Introduction to Clinical Neurology, 2nd ed. Boston: Butterworth Heinemann, 2000.

23. Gilman S. Clinical Examination of the Nervous System. New York, McGraw Hill, 2000.

24. Spillane J, Bickerstaff ER. Bickerstaff's Neurologic Examination in Clinical Practice. Birmingham: Blackwell,
1996.

25. Swartz MH. Textbook of Physical Diagnosis, 4th ed. Philadelphia: WB Saunders, 2002.
Table 1. Common errors made by trainees

Examination component Common errors

Visual fields Failure to test
Fundi Failure to test
Pupil examination Having the patient fix at near (simultaneous light and
near stimulus, will always miss light-near dissociation)
Extraocular movements - Omission
Using four movements rather than six, checking
vertical gaze in primary position rather than eccentric
position to each side
Facial nerve examination Relying solely on the purse your lips/puff out your
cheeks technique (will only detect fairly marked facial
weakness, not sensitive to mild or subtle facial
weakness, poor screen for CNS disease, never
detects a dissociated facial, and fails to examine
upper face movements)
Palatal assessment Overcalling insignificant palatal deviation
Tongue Being duped by insignificant minor deviations or
"pseudodeviation" due to facial weakness
Motor examination Failure to exert sufficient force to truly test a muscle’s
strength, using only a cursory push sufficient to detect
only gross weakness
Failure to understand the MRC scale
Failure to adjust for examiner/examinee strength
mismatch
Using only grip to test upper extremity strength
Sensory testing Failure to adequately instruct the patient
Failure to perform double simultaneous stimulation
Failure to check vibratory sensation
DTRs Poor hammer
Poor technique in general (too much elbow, too little
wrist, no velocity at hammer head, [“its racketball, not
tennis”]; putting the index finger on top of the handle;
striking with a decelerating blow ("pecking");
Poor technique for specific reflexes
ankle jerks - difficulty both with proper stretch on the
tendon, and efficient striking (teacher and trainee
switch off holding and hitting)
Not using reinforcement with difficult to elicit reflexes
Plantar responses Insufficiently firm stimulation
Placement of the stimulus too medially
Moving the stimulus too quickly ("striking a match")
Cerebellar Omission
Gait and station Omission
Table 2. Books on the neurologic examination

Books devoted to the neurologic exam

Small paperbacks
Goldberg, The 4 Minute Neuro Exam
Fuller, Neuro Exam Made Easy
Lewis, Field Guide to the Neurologic Exam
Massey, et al., Diagnostic Tests in Neurology

Medium paperback
Ross RT, How to Examine the Nervous System
Nolan, MF (physical therapist). Introduction to the Neurologic Examination
Alpers, Alper’s and Mancall’s Essentials of the Neurologic Examination
Harrison, MJG, Neurologic Skills: A Guide to Examination and Management in Neurology
DeMyer W.E, Technique of the Neurologic Examination: A Programmed Text
Glick T, Neurologic Skills: Examination and Diagnosis

Small hardback
Gilman, Clinical Examination of the Nervous System
Mayo Clinic Staff, Mayo Clinic Examinations in Neurology
Spillane and Bickerstaff, Bickerstaff’s Neurologic Examination in Clinical Practice

Large hardback
Campbell, DeJong’s the Neurologic Examination

Physical examination books with neurologic examination sections

Bates B, et al., Bates' Guide to Physical Examination & History Taking

DeGowin RL, et al., DeGowin's Diagnostic Examination
Swartz MH, Textbook of Physical Diagnosis

Large textbooks with neurologic examination chapters

Joynt RJ, Griggs RC, Baker's Clinical Neurology

Small textbooks with neurologic examination chapters

Gelb DJ, Introduction to Clinical Neurology

Campbell WW, Pridgeon RM, Practical Primer of Clinical Neurology
Table 3. A selection of useful websites for teaching the neurologic examination.

Neurological examination

www.vnh.org/FSManual/07/02GeneralNeurol.html

cim.ucdavis.edu/eyes* (note: no www)

www.richmondeye.com/eyemotil.asp*

www.revoptom.com/handbook/section6.htm

medinfo.ufl.edu/year1/bcs/clist/neuro.html

www.neuroexam.com/

www.conntutorials.com/video.html

missinglink.ucsf.edu/lm/IDS_104_neuro_exam/NeuroExam.html

Neurology metasites with many links to examination related sites

www.neuroland.com

www.neuroguide.com

medlib.med.utah.edu/neurologicexam/html/home_exam.html

www.neuropat.dote.hu/neurology.htm

www.toddtroost.com/mylinks2000.html

*wonderful interactive areas for learning about abnormal eye movements and pupils
 Teaching the neurologic
examination in the 21st
century

Teaching the neurologic

examination in the 21st
century
• Whether to teach it
• Who to teach
• How to teach
 Whether to teach it

"Is the neurologic

examination becoming
obsolete?"
Ziegler DK. Neurology1985;35:559
Two countervailing
sentiments
•Pro-technology
•Anti-technology

Pro-technology
Neurosurgical aphorism:
One ___________(MRI,CT,
A/G, PEG, etc, depending on
the era) is worth a roomful of
neurologists.
Anti-technology
“There has been within recent
years an interesting tendency to
rely more and more on laboratory,
mechanical and other such
methods...at the expense of
careful clinical observation."
Sir Gordon Holmes, 1953

If we conclude that the

techniques of the neurologic
exam are worth continuing
to teach to medical students
and residents, how do we
go about the task.
 WHO TO TEACH

Influence of attending behavior on student

learning of the neurologic examination
during a neurology clerkship

Housestaff divided attendings into 3 groups,

rated as teachers of the neurologic exam

Good - made it a point to teach exam

techniques

Average – cursory exams, some teaching

Poor - rarely or never examined a patient,

rarely or never demonstrated abnormal
physical findings, no effort to teach exam.
 End of rotation neuro exam
assessment
Entire 3rd year class (161 students)
divided into 3 groups and analyzed
according to examination teaching style of
the attending who had supervised their
rotation.

Analysis of variance

Linear regression

Conclusion
No demonstrable relationship between attending
attributes re teaching examination technique and
student performance of examination at end of
rotation

Implication
Teach the residents

Encourage the residents to teach the students

However - study of internal medicine
residents found that almost one third spent
no time whatsoever at the bedside
teaching physical examination to students.

Smith MA, et al. Medical students' perceptions of their

housestaffs' ability to teach physical examination skills.
Acad Med. 2003;78:80.

HOW TO TEACH
 Finding time to teach
• Never been easy; getting harder
– Time to Heal: American Medical Education from the
Turn of the Century to the Era of Managed Care, K.
M. Ludmerer
– describes how time constraints imposed by managed
care, rampant medical commercialism and other
factors are compromising medical education.
– reform not likely soon
• Juggling act between teaching and patient care
has always been difficult to do, but it is not
impossible.

Two fundamental approaches

to teaching the examination
• Passive
• Active
 Passive teaching
Student left to learn the
examination largely on their
own, through trial and error, by
reading textbooks, generally
not satisfactory; does not lead
to very well developed
examination skills.

Active teaching
At least three ways
Demonstration
Simulation
Observation
Incorporating the general physical
into the neurologic examination
• Frequent request: “Teach me how to
incorporate the neurologic examination
into the general physical.”
• Answer: Turn concept on its ear and think
about incorporating the general physical
into the neurological exam.
• Works well, well received, appreciated
• Very efficient

Any neurological
examination, even a cursory
one, provides an opportunity
to accomplish much of the
general exam. Neurologic
exam does not have to be a
separate process
 Incorporating the general physical
into the neurologic examination
• Cranial nerve exam accomplishes much of
the HEENT exam
• Motor, reflexes, gait and station - great
deal of information about orthopedic
condition
• Testing sensation/plantar responses -
opportunity to coincidentally examine skin
and nails and feel the peripheral pulses

Incorporating the general physical

into the neurologic examination
• Auscultate carotids - little additional effort
to palpate the neck for masses and
thyromegaly.
 At the end of a good
neurological exam, one only
has to listen to the heart and
lungs and palpate the
abdomen to have also done
a fairly complete general
physical examination.

Demonstration teaching
• Trainees watch mentor examine patients
– Student watching resident or attending
– Resident watching attending
• Requires running narrative while
simultaneously examining and interacting
with the patient
• Lack of narrative degrades effectiveness
• Perceived as boring
 Demonstration teaching
best done at the bedside
• Debate on pros and cons of
bedside teaching
• Conference room rounds,
"doctoring the chart“

Rules for bedside presentations

and examinations
• Students must understand the rules of
engagement
• Patient must be involved in the process,
not made to feel like an object
• Euphemisms used for any terms that may
cause concern for the patient
 More rules for bedside
presentations and examinations
• Certain terms (e.g., cancer, AIDS, MS,
ALS) are forbidden at the bedside
• The speaker must pay careful attention to
what they are about to say; pre-edit
• Visit to the patient after rounds to answer
any questions and allay any concerns that
may have arisen during the bedside
encounter

• Rely primarily on demonstration

for the first several days to a
week (assuming a four-week
rotation)
• Making active effort to teach
examination technique
• For remainder of rotation rely on
combination of simulation and
observation.
 Simulation teaching
• Trainee examines a person who is not an
actual patient, under the watchful eye of
the teacher.
• Formal simulated patient (e.g., simulation
center) – lay person trained to give a
history of a particular condition, and
sometimes to simulate physical exam
findings, such as a Babinski sign.

Informal simulation
• Another member of clinical team
– Attending – best by far
– Resident
– Student
• Posits a clinical scenario
• Imitates exam findings
• Use simulated new patient if no actual new
patient
 Examples of findings readily
simulated
• Hemiparesis, from mild to severe
• Facial weakness (central or peripheral,
unilateral or bilateral)
• Sensory loss in a particular distribution
• Visual field deficits
• Upgoing toe and certain other pathological
reflexes

Findings readily simulated

• Higher cortical function deficits – aphasia,
agnosia, extinction, neglect
• Other types of focal weakness (ulnar
neuropathy, radial nerve palsy, foot drop),
proximal weakness, distal weakness
• Abnormal movements, tremor, etc
• Carotid bruit
Central facial
 Peripheral facial

Simulation of eye movement

abnormalities
• Hand movements
• Web sites
–cim.ucdavis.edu/eyes
–www.richmondeye.com/eyemotil
.asp
 cim.ucdavis.edu/eyes/version15/eyesim.html
http://
www.richmondeye.com/eyemotil.asp
The Monty Python Ministry of Silly Walks
 Abnormal gaits easily imitated
• Hemiplegic gait
• Parkinsonian gait, festination
• Spastic diplegia
• Cerebellar ataxia
• Sensory ataxia
• Foot drop (mild/severe, unilat/bilat),
• Trendelenberg gait
• Marche a petit pas

Fundus examination simulation

Conditions well demonstrated using
fundus simulation

• Papilledema (varying degrees,

acute, chronic)
• Drusen
• Optic atrophy
• Diabetic/hypertensive retinopathy
 Teaching by observation
• Watching a trainee conduct an
examination on a patient or a normal
control.
• Consistent finding in studies of clinical
teaching has been the lack of direct
observation of trainee interactions with
patients.

Few students report having

been monitored while interviewing
or examining more than 1 or 2
patients during their entire
medical school careers, and a
surprising number graduate
without having been supervised
or observed while working up
even one patient.
• Errors often surprising,
sometimes astounding, e.g.,
stimulation of the sclera
rather than the cornea for
the corneal reflex
• Common errors and
omissions (see handout)

TAG TEAM NEUROLOGIC

EXAMINATION
• Each student specializes in a given part of
the examination for a set period of time
(e.g., 1 week)
• During a given week, one students does
all the cranial nerve exams, another all the
motor exams, etc
• Students rotate responsibility for different
parts of the exam.
• Evaluating new patient, students do a
“team” examination
EXAMINATION FOCUSED DAILY
WARD ROUNDS
• Single part of exam done on every patient
by every trainee
– Ankle jerk rounds
– Toe rounds
– Eye movement rounds
• Marked improvement in technique in a
relatively short period of time.

THE COLD PATIENT EXERCISE

• Trainee performs 20 minute evaluation on
an unknown patient under observation of
attending and rounding group
• Use new patient admitted to another team
member
• Other team members critique exam
• Attending does whatever is necessary to
clarify situation
• Trainee “love-hate” relationship
 Resident as attending
• Role reversal exercise, can be very
elucidating
• Resident functions as attending; students
present to resident, attending observes
• Resident responsible for evaluating the
patient and teaching the students during a
particular new patient encounter

Resident as attending
• Afterwards, attending does what is
necessary to clarify the situation, then
critiques the residents performance
• Works best with senior, experienced
residents
 RESOURCES FOR
TEACHING THE
EXAMINATION

•Print
•Electronic

Books devoted to neurologic exam

• Small paperbacks, e.g., Goldberg, S. The
4 minute neuro exam
• Medium paperback, e.g., Ross RT, How to
examine the nervous system
• Small hardback, e.g., Mayo clinic
examinations in Neurology
• Large hardback, Campbell WW. DeJong’s
The neurologic examination
 Alpha Omega

56 pages, $12.95 640 pages, $110.00

• Physical examination books with neurologic

examination sections
– Bates B, et al, Bates' guide to physical examination &
history taking
– DeGowin RL, et al, DeGowin's diagnostic examination
– Swartz MH. Textbook of physical diagnosis
• Large textbooks with neurologic examination
chapters
– Joynt RJ, Griggs RC, Baker's clinical neurology
• Small textbooks with neurologic examination
chapters
– Gelb, Introduction to clinical neurology
– Campbell and Pridgeon, Practical Primer of clinical
neurology
 Useful websites
• Neurology metasites with many links to
examination related sites
– www.neuroland.com
– www.neuroguide.com
– medlib.med.utah.edu/neurologicexam/html/ho
me_exam.html
– www.neuropat.dote.hu/neurology.htm
– www.toddtroost.com/mylinks2000.html

http://www.neuropat.dote.hu/neurology.htm
 Sample of neurological
examination websites
• www.vnh.org/FSManual/07/02GeneralNeurol.ht
ml
• cim.ucdavis.edu/eyes
• www.richmondeye.com/eyemotil.asp
• www.revoptom.com/handbook/section6.htm
• medinfo.ufl.edu/year1/bcs/clist/neuro.html
• www.neuroexam.com
• www.conntutorials.com/video.html
• missinglink.ucsf.edu/lm/IDS_104_neuro_exam/N
euroExam.html
http://missinglink.ucsf.edu/lm/IDS_104_neuro_exam/NeuroExam.html
http://medlib.med.utah.edu/neurologicexam/html/home_exam.html