Pauline Anderson

June 03, 2015

INDIANAPOLIS, Indiana — Are neurology residents getting it right when it comes to diagnosing multiple sclerosis (MS)? A new study suggests that the diagnostic accuracy for MS among first-year neurology residents falls short of that for stroke and seizures.

"This gives us a good benchmark of how our residents do and what they know at the beginning of their training," said Stephen Krieger, MD, director of the residency program and associate professor, neurology, Mount Sinai, New York.

He presented his research at a poster session during the Consortium of Multiple Sclerosis Centers (CMSC) 2015 Annual Meeting.

For three consecutive academic years, Dr Krieger and his colleagues entered information on patient assessments by neurology residents during their daily morning report sessions into a database. These sessions are part of the standard neurology education program.

"This is a case log of patients that these junior residents see for the first time, say in the emergency room or on night call. Then, that morning they present the cases they saw to a group of residents and faculty, and we discuss what they think was going on," said Dr Krieger.

After recording the resident's initial diagnostic impressions, researchers revisited each case after reviewing the final diagnosis to see whether the residents were correct.

Of 834 cases, 73.2% were seen in the emergency department (ED), 19.9% were in-hospital cases, and 6.9% were transfers from other hospitals. A total of 604 cases (74.1%) were neurologic.

There were a total of 198 diagnostic errors. The residents did better in accurately diagnosing neurologic cases than non-neurologic (eg, psychiatric) cases (70.9% vs 60.3%; P = .001).

They were most accurate in diagnosing stroke (82.3%) and seizure (75.6%). This makes sense, said Dr Krieger, because these were the most common presentations.

The doctors were least accurate in diagnosing headache.

As for MS, the residents were about 74.2% accurate. "That's a good start; it means that they're coming in with a level of knowledge and the beginnings of good clinical acumen and then they refine that over the rest of their training," said Dr Krieger.

The residents wrongly diagnosed demyelinating disease when patients were ultimately deemed to have other conditions, such as neoplasm, neuropathy, or psychiatric illness. On the other hand, they mistakenly diagnosed cases of central nervous system infection, medical illness, trauma, and neoplasm as demyelinating disease.

"For the ones that they overcalled as MS, it was most often things that can cause fatigue or other phenomena that could be confused as MS," said Dr Krieger.

 
It speaks to the importance of maintaining diagnostic humility; no one is right all the time. Dr. Stephen Krieger
 

He pointed out that not even doctors who have been practicing for years are always 100% correct in their diagnosis of MS. "It speaks to the importance of maintaining diagnostic humility; no one is right all the time."

First-year residency is a "crucial time for future neurologists to learn clinical acumen, to learn how to make certain diagnoses," he said.

Tailoring Teaching

By highlighting the types of errors made, the project is a good opportunity to "tailor" the teaching program, noted Dr Krieger. Another positive aspect of the study was that it gave residents feedback about their knowledge level.

And it challenged them. "It was a little competitive; they wanted to be right," said Dr Krieger.

Asked to comment on the results, Robert Lisak, MD, professor, neurology, Wayne State University, Detroit, Michigan, and president of the CMSC, said they are "a bit surprising" and "concerning."

There is "so much emphasis on strokes, headaches, and seizures" in patients coming though the emergency department or from in-patient services that may have "more dramatic" presentations than MS, said Dr Lisak.

"Some residents may not think of MS, particularly if it is an atypical presentation, or if an MRI scan is not classical in appearance."

Consortium of Multiple Sclerosis Centers (CMSC) 2015 Annual Meeting. Poster CC 18. Presented May 29, 2015.

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