A Diverse Specialty: What Students Teach Us About Neurology and "Neurophobia".

OBJECTIVE: To explore what elective students learn about the specialty of Neurology. METHODS: A prospective qualitative study using pre- and post-elective written questionnaires. RESULTS: Analysis concentrated on three main themes: What did students learn about the specialty of Neurology? What would they change about their experience? Did their opinions change? Major findings were (i) pre- and post-elective the most frequent response for "what is the best thing about Neurology?" was the "process of localization" and (ii) post-elective students were less likely to cite the challenge or problem-solving aspect of Neurology as the best thing while more emphasized the importance of the physical exam and the variety of cases. (iii) Students were most surprised by the scope of neurological practice. (iv) They would diversify the setting of their elective to include less time spent in the emergency room and more time in clinic. (v) The perception of Neurology as a specialty in which patients have a poor prognosis was the opinion that changed the most. CONCLUSIONS: Showcasing the diversity of cases and careers in Neurology may be a useful strategy to increase interest in the specialty and reduce neurophobia. Lectures or small groups early in medical school should concentrate on clear examples of common neurological conditions and emphasize the role of general neurologists and subspecialists involved in patient care. Whenever possible students should rotate through different clinics and not concentrate exclusively on emergency room and in-patient cases.

The usefulness of gadolinium-enhanced images on a follow-up magnetic resonance image in suspected multiple sclerosis.

PURPOSE: Multiple sclerosis diagnostic criteria include the presence of gadolinium-enhancing lesions when determining dissemination in space and time. Gadolinium is expensive, increases scan time and patient discomfort, and can, rarely, cause serious adverse effects. Our objective was to determine the usefulness of including gadolinium-enhanced images as part of a follow-up brain magnetic resonance imaging (MRI) in patients with a clinically isolated syndrome. METHODS: Consecutive patients seen between 2008 and 2010 with a clinically isolated syndrome suggestive of multiple sclerosis were prospectively enrolled, had a non-gadolinium-enhanced brain MRI, and consented to a follow-up gadolinium-enhanced brain MRI. The primary outcome was a comparison of the number of patients diagnosed with multiple sclerosis compared with the number who would have been diagnosed without the gadolinium-enhanced images. RESULTS: Twenty-one patients enrolled, and 2 withdrew. Follow-up MRIs were performed a median of 241 days after the initial MRI. Eleven patients met the primary outcome and were diagnosed with multiple sclerosis: 6 as a result of a second clinical attack and 5 by using imaging criteria for dissemination in space and time. If the gadolinium-enhanced images had not been obtained, then there would have been no change in the primary outcome. CONCLUSIONS: In Canadian centers with similar MRI waiting times to those in our study, the routine use of gadolinium as part of a follow-up MRI in patients with suspected multiple sclerosis may not be clinically useful. Gadolinium-enhanced images could still be obtained on an as-needed basis for specific clinical indications.

Improving the neurological exam skills of medical students.

OBJECTIVE: Determine if distributed practice of of neurological exam (NE) skills in first year medical school produces sustained improvements in the skills of second year students. METHODS: A prospective, controlled, non-blinded study conducted at McGill University (class size = 180 students). Expanded teaching of muscle stretch reflexes was provided to first year medical students. A structured examination of muscle stretch reflexes (max score = 100) was administered in second year medical school after a required two week rotation in Neurology. Results for class A (received the intervention in first year) were compared to the results for the preceding class B (had not received the intervention). RESULTS: 77 of 177 (44%) eligible in class A and 69 of 166 (42%) eligible students in class B participated. Results were analyzed separately for each of the two examiners. Mean (SD) scores were 95.2 (5.6) for class A (intervention) and 81.7 (11.1) for class B (control) for the first examiner and 90.4 (8.2) for class A and 83.8 (11.7) for class B for the second examiner. Results were statistically significant (Mann-Whitney test z = 5.27, p<0.0001 first examiner and z = 2.67, p<0.0038 second examiner). CONCLUSIONS: Distributed practice of muscle stretch reflexes during first year medical school results in improved performance by second year medical students after their mandatory clinical rotation in neurology, even when examined up to 14 months after the intervention. This finding has implications for the teaching of the NE.

EEG in suspected syncope: do EEGs ordered by neurologists give a higher yield?

BACKGROUND: Prior studies have shown that the electroencephalogram (EEG) is of low diagnostic yield in the evaluation of syncope but have not looked at the yield according to referring physician specialty. The goals of this study were to determine if the yield of the EEG is higher when ordered by neurologists and whether EEGs with abnormal findings resulted in any significant change in patient management. METHODS: We retrospectively reviewed the records of the EEGs requested for a clinical diagnosis of syncope, convulsive syncope, loss of consciousness, or falls from 2003 to 2007 at our institution. We obtained further information from the medical record of patients with an abnormal EEG. RESULTS: Of 517 EEGs meeting our inclusion criteria, only 57 (11.0%) were read as abnormal. No EEG was positive for epileptiform activity and only 9 (1.6%) showed potentially epileptic activity. EEGs ordered by neurologists did not have a higher yield compared to non-neurologists. Five abnormal EEGs resulted in further investigations being ordered. One patient was ultimately started on phenytoin. CONCLUSIONS: EEGs requested for the evaluation of patients with suspected syncope have an extremely low diagnostic yield and do not significantly alter the management of the patients, regardless of the specialty of the referring physician.

Radial neuropathies in wheelchair users.

This report presents two cases with a radial neuropathy caused by compression between the spiral groove of the humerus and a hard wheelchair surface. One case involved the arm rest and the second a hard, vertical support of the back of the wheelchair. Close attention to the placement of the upper arms in relation to the surfaces of the wheelchair is required to avoid this complication in wheelchair users.

The essential neurologic examination: what should medical students be taught?

BACKGROUND: Graduating medical students often identify the neurologic examination (NE) as one of the clinical skills with which they are least comfortable. We hypothesized that this is because they are unsure about which elements of the NE are important, and conducted a study 1) to identify whether neurologists agree about the essential elements of the NE and 2) to determine whether the views of medical students about what is essential differ from those of neurologists. METHODS: Using a Delphi process, we asked McGill University neurologists which elements of the NE they would perform at least 80% of the time in a common clinical scenario. We confirmed the results in a sample of Canadian neurologists, and then compared the results of the McGill neurologists to a sample of graduating McGill University medical students. RESULTS: The neurologists surveyed rated 22 items of the NE as essential, and there was a high degree of consensus about which items were essential. Medical student ratings of the importance of NE items were largely similar to those of the neurologists, although there were some noteworthy discrepancies. CONCLUSIONS: The anxiety felt by medical students regarding the neurologic examination (NE) seems unlikely to be solely due to uncertainty about which elements of the NE are important. Expert consensus about the essential elements of the NE and awareness of areas where neurologist and student views differ should be used to guide teaching of the NE.

How well does neurology residency mirror practice?

OBJECTIVE: To report the residency training experience of two neurologists, focusing on setting and diagnoses encountered. METHODS: Data from prospective patient logs kept by the authors during residencies completed a decade apart were compared with each other and the literature. RESULTS: The range of diagnoses was broadly similar between residencies, as were the proportions of common or uncommon disorders, and the proportion of cases without a neurological diagnosis. Although most patients were seen in in-patient settings, the rates at which common neurological conditions and functional disorders were seen was comparable to published experiences of community neurologists. CONCLUSIONS: The diagnostic profile of North American neurology residency appears to be relatively stable, regardless of location or date of training. In several respects, the content of current neurology residencies mirrors clinical practice well. Changes to residency training are doubtless needed, but they should be guided by a clear understanding of the experiences of contemporary trainees.