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

Environment Factors

Utilizing Technology Appropriately

Technology is ubiquitous within most aspects of medicine, including medical education.[107] Several definitions refer to technology in education, including e-learning (using the Internet for computer-assisted instruction or distance learning), multimedia learning (using two or more types of media such as graphics or animation on a computer; this definition preceded the use of the Internet and e-learning), and blended learning (combining e-learning with traditional instructor-led training).[108] Neurological examination teaching has embraced these techniques, with the literature providing examples of videotaped vignettes and Web sites (Table 2).[109,110]

The advantages of using e-learning include increased accessibility to information, ease for teachers to update content, learner control over content and pace, ease of distribution, standardization of content, and accountability through built in tracking and assessment.[108] The evidence behind it has been systematically reviewed across four domains: knowledge gains, learners' attitudes, learning efficiency, and cost–benefit.[111] For knowledge gains, e-learning improves post-test multiple-choice scores when students are given tests before and after it. It is otherwise comparable, but not superior, to more traditional educational techniques. For learners' attitudes, it is preferred over slide/tape and text-based materials. For learning efficiency, there is no definitive advantage with one study showing a time benefit compared with text-based learning, but another study showed conflicting results. For cost–benefit, the review did not feel the existing literature had thoroughly evaluated this domain. A benefit has been shown in subsequent studies, with one calculating a 24% savings when excluding transition.[112,113]

Simulation has become a hot topic in medical education, although the current limitations of simulation devices make replicating the neurological examination difficult if not impossible.[114] Simulation can, however, be effective in teaching neurological procedures such as lumbar punctures or training for emergent neurological scenarios like status epilepticus.[115,116] It is important to realize that innovation in teaching the neurological examination does not necessarily require the latest technological advancements. One study reported the benefits of simply having a "Neurostand" with the equipment required to perform an examination.[117]

Adapting the Examination for Technology

Telemedicines, including teleneurology and telestroke, are becoming increasingly common. They allow neurology services to be provided to people who otherwise might not have access, including in rural or remote areas.[118] It has been shown that patients can be examined remotely, including with the NIHSS in the case of acute stroke.[119] Typically there will be a telepresenter who can help with more detailed examination maneuvers such as reflexes, with these examinations comparing favorably to face-to-face examinations.[120] A recent survey of neurology departments found that 63% thought teleneurology was equivalent to in-person care, 31% thought it was inferior, and 3% thought it was superior.[121] Two of the challenges moving forward include ensuring that telepresenters are competent at eliciting examination maneuvers and that neurologists can instruct the telepresenter and patient remotely. A proposed teleneurology curriculum has been developed that incorporates clinical skills.[122]

Matching Teaching to the Environment

The clinical environment has evolved to be faster paced and there are time pressures on everyone involved. Medical students have a busy curriculum combining clinical time with didactics. Teachers, including trainees and attending physicians, have their own time pressures, with interns spending only 12% of their time with patients due to other demands.[123] This lack of time applies to teaching, with 8% of interns and 36% of trainees spending no time teaching examination skills at the bedside.[124] Patients are also now admitted for shorter periods of time.[125] The importance of allocating time cannot be underestimated. A 1-hour outpatient session with a faculty member during neurology clerkships increases exposure to a comprehensive history and examination from 38 to 57%.[126] Both a didactic on the broader neurological examination and a targeted 15-minute session on ankle reflexes improve ability to elicit ankle reflexes.[127] Neurology care teams have therefore adopted several strategies to effectively teach the neurological examination in this environment (Table 3).

Peer-assisted learning is a way overcoming some of the time challenges. It involves more senior students teaching junior students and has repeatedly been shown to be effective for teaching clinical examinations.[128–133] A recent online tool at the University of Toronto has facilitated students giving feedback to peers.[109] It contains criteria for a student to assess a second student as they examine a third student; the completed assessment can then be emailed to the second student. The Web site additionally contains guides to the different examinations (although the neurology components were still being developed as this article was prepared). The Web site was accessed over 16,000 times in a year from around the world.