Teaching the Neurological Examination in a Rapidly Evolving Clinical Climate

James M. Hillis, MBBS, DPhil; Tracey A. Milligan, MD, MS, FAAN


Semin Neurol. 2018;38(4):428-440. 

In This Article

Abstract and Introduction


The neurological examination remains the essence of neurology. It allows symptoms to be assessed, diagnoses to be made, and dynamic functions to be followed. Skill in the neurological examination has faced increasing challenges from the encroachment of diagnostic imaging, but has maintained its clinical utility. It has also encountered the battle for the precious time within a medical curriculum. This review considers how the neurological examination can best be taught into the future. It does so by considering factors related to the examination, the learner, the teacher, and the modern clinical environment.


The neurological examination originated with luminaries including Joseph Babinski and Wilhelm Erb in the late 1800s.[1] Like any physical examination, it aims to prove or disprove differential diagnoses that are hypothesized from a patient's history.[2,3] It provides physicians with a pattern of findings to suggest a neuroanatomic location; this pattern and location then correspond with pathophysiologic processes. A patient with altered vibratory and proprioceptive sensation in both lower extremities, for example, could have posterior column disease that stems from vitamin B12 deficiency, copper deficiency, or syphilis. The neurological examination also allows physicians to monitor the functional progression of a disease, including a patient with recovering aphasia after a stroke or a patient with motor neuron disease and worsening weakness. There are now entire textbooks devoted to describing the myriad maneuvers of the examination.[1,4] A systematic examination has also evolved that evaluates mental status, cranial nerves, motor function, coordination, gait, reflexes, and sensation.[5–7]

The current clinical environment and its reliance on diagnostic testing have, however, led to a decline in physical examination competence.[8–13] Students perform worse on the neurological examination compared with all other components of the United States Medical Licensing Examination (USMLE) Step 2 Clinical Skills.[14] When incoming interns encounter a simulated patient with altered mental status, 80% request a head computed tomography (CT), yet only 41% perform a neurological examination.[15] Among inpatients who have neurology consults, 33% do not recall being examined with a reflex hammer prior to involvement of the neurology team.[16] It is clear that there is room for improvement in teaching and using the neurological examination moving forward. We detail current strategies by considering the factors relating to the examination, the learner, the teacher, and the environment.