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

Learner Factors

Teaching to the Adult Learner

The nature of medical training has changed significantly over recent decades. It has focused increasingly on ensuring students and trainees develop specified competencies.[55,56] It has also focused less on didactic lectures and more on problem- or team-based learning. The rationale is that students cannot learn an entire medical curriculum but can develop skills to be lifelong learners and adaptable practitioners.[57] The AAMC recommends a similar strategy for clinical skills including the physical examination with the view that "engendering the habit of skill learning should be the ultimate goal of a clinical skills curriculum."[7]

The flipped classroom is a teaching method that epitomizes these principles. It involves students preparing for classes ahead of time with online videos and other materials, answering several embedded questions to demonstrate their mastery, and then participating in problem solving and other exercises during the actual class time.[58] It is considered flipped because the teaching occurs on students' own schedules ahead of class, and the homework then takes place in class. The flipped classroom method applies well to the physical examination in that students can prepare before having the opportunity to practice the examination with an experienced clinician. It has also been shown that closely supervised teaching of the physical examination leads to improved performance and comfort with the examination.[50,59] An overview of online videos and other instructional materials is included in Table 2.

Embracing the Millennial Learner

Millennials, or Generation Y, are the generation born between the early 1980s and late 1990s. Medical students from this generation are motivated more than Generation X by achievement ("doing something better" with "an implicit or explicit standard of excellence"[60]) and affiliation ("establishing, maintaining, or restoring a positive affective relationship with another person(s)"[61]), and less by power ("the desire to have impact on other people, to affect their behavior or emotions"[62]).[63] They also score lower on scales for self-reliance and higher for assertiveness, self-liking, narcissistic traits, high expectations, and some measures of stress, anxiety, and poor mental health.[64] The optimal teaching strategies include appreciating the differences in the way they learn compared with previous generations, maximizing techniques that match their qualities such as team-learning and collaboration, utilizing technology appropriately, and being mindful of their limitations such as their belief that they are successful in multitasking when in actuality more focused attention is necessary.[65,66]

A recent teaching initiative involved students interviewing and then examining a patient while a neurologist observed and generated documentation.[67] Its key aim, in which it succeeded, was to demonstrate how neurologists can maintain clinical productivity while directly observing students. Beyond that, however, it implicitly utilized millennial students' motivations by achievement and affiliation, and 90% of students gave the highest ranking for how it impacted their clinical skills. The concept of collaboration can be expanded to include patients, especially with the uptake of shared decision making in clinical care.[68] Bedside teaching allows patients to learn about their illnesses as well as to "revel in the bedside repartee, and feel finally that physicians are interested in them and are communicating with them."[69]

Recognizing That Assessment Drives Learning

Assessment is known to drive learning during medical training.[70–74] The AAMC recommends a clinical skills assessment and feedback process that exists throughout the medical school curriculum.[7] The ability to demonstrate learning of a clinical skill involves Miller's sequential steps of knowledge (knows), competence (knows how), performance (shows how), and action (does).[75] Different assessment methods evaluate these levels of learning: multiple-choice questions show knowledge, oral examinations or written essays demonstrate competence, standardized patient examinations or objective structured clinical examinations (OSCEs) show performance, and direct observation with patients or portfolios involving 360 evaluations demonstrate action (Figure 1).[6] There are similar stages that define skill acquisition: novice, competence, proficiency, expertise, and mastery.[76] The AAMC suggests that the expected levels of demonstrated learning and skill acquisition be considered when choosing an assessment method.[6] Interestingly, the ability to perform the physical examination well in one type of assessment does not necessarily correlate with other types of assessment.[77] The ability to perform a neurological examination does, however, correlate better than examinations of other systems with the ability to perform a head-to-toe examination.[78]

Figure 1.

Miller's framework for clinical assessment with suggested assessment methods.6,75