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

Teacher Factors

Training Teachers to Teach

The importance of skills development in medical education is increasingly recognized.[79–83] At a broad level, the key roles for medical educators include being an information provider, role model, facilitator, assessor, planner, and resource developer.[84] While direct teaching of the neurological examination mostly involves being an information provider, role model, and assessor, the other areas must be considered at a systems level. The competencies that follow for individual educators include content knowledge, learner centeredness, interpersonal and communication skills, professionalism and role modeling, practice-based reflection and improvement, and resource utilization within the larger system.[79] The qualities of "good" clinical educators also include the formation of positive relationships with students, the creation of a supportive learning environment, and enthusiasm.[85]

There is growing number of courses and other initiatives available to train both trainees and attending physicians as educators. A review of physician as teacher initiatives found that participants were overall highly satisfied, and both participants and their students had observed changes in teaching behavior.[83] The initiatives that were particularly worthwhile involved the use of experiential learning, provision of feedback, effective peer and colleague relationships, well-designed interventions following principles of teaching and learning, and the use of a diversity of educational methods within single interventions. A review of trainee as teacher courses also reported high satisfaction and improved knowledge of educational principles, although concluded that a more rigorous study design was required to determine the true effectiveness of such courses.[86] One child neurology residency program has incorporated a 2-year longitudinal teaching curriculum.[87] It has increased trainees' self-assessed skill in promoting clinical reasoning, ability to determine the level of a learner, and comfort and skill in delivering feedback.

Multiple articles detail specific tips for teaching the physical examination.[88–91] A key model they suggest is Peyton's four-step approach to skills learning: demonstration (trainer demonstrates at normal speed without commentary), deconstruction (trainer demonstrates while describing steps), comprehension (trainer demonstrates while learner describes steps), and performance (learner demonstrates while learner describes steps).[88,92] An additional two steps involve assessing a student's knowledge and learning needs prior to demonstrating, and obtaining feedback including from the patient after performance (Figure 2).[91] Similar to the broader medical education competencies, student feedback has indicated the value of didactic, interpersonal, and communication skills in teaching the physical examination.[52] Student feedback also suggests the importance of two-way integration of skills training with the broader curriculum, structured training, the delivery of a summary at the end of a training session, sufficient knowledge on the part of the teacher, adequate preparation by the teacher, and proper time management.[52]

Figure 2.

Adaptation of Peyton's four-step approach to skills learning.91,92

Ensuring Teachers Provide Feedback

Feedback is crucial in teaching a physical examination as it is in medical education overall.[93,94] Both trainees and attending physicians feel it is the most important teaching skill for attending physicians to have.[95] When the USMLE Step 2 Clinical Skills examination was developed in the early 2000s; however, nearly 40% of students indicated that they had been observed four times or less performing a history and physical examination by a faculty member.[96] That number is consistent with attending physicians' views, with 45% reporting that they have not had the opportunity to give students feedback.[97] The suggestions for addressing this deficiency include development of core clinician–educator faculty, higher prioritization of clinical skills evaluation by faculty leaders, and outcome measurement for clinical skills training.[96]

Students can also gain feedback from patients including simulated patients.[98] A study has shown that patient instructors, who are standardized patients who teach the physical examination without associated faculty, provide feedback of equal quantitative value compared with physicians about key examination components, mistakes, and communication.[99] However, qualitative feedback, especially constructive feedback, is better from physicians.

Rewarding Faculty who Teach

Teaching the neurological examination ultimately requires teachers. There is a common perception though that teaching is less valued compared with clinical practice, research, and administration.[97,100,101] It therefore competes with these areas for neurologists' time. The literature consistently suggests that department and faculty leaders should be further enshrining the role of teaching.[82,90,102] They can do so financially through salary, time allocation, and administrative support, or nonfinancially through teaching recognition awards and consideration of teaching in promotion criteria. Clinicians additionally enjoy teaching.[97,100,101] Academic practice neurologists have higher rates of career satisfaction and quality of life, as well as lower rates of burnout, compared with clinical practice neurologists.[103] The largest driver of career satisfaction is the meaningfulness neurologists and neurology trainees find in their work[103,104] and training the next generation of physicians is part of a physician's professional identity and responsibility.[105] Teaching the physical examination is a key means of incorporating the traditional apprenticeship model of education in modern clinical settings.[106]