Neurology clerkship

What is neurology?

Neurology is the branch of medicine that deals with disorders of the central, peripheral, and autonomic nervous systems. It takes 4 years to become a neurologist: one year of training in internal medicine (internship), and 3 years of training in neurology (residency). Further specialization takes 1–4 years of fellowship, depending on the specific field.

• Involves the main disciplines of the neurosciences:
  • Neuroanatomy: the study of the anatomical structures and organization of the nervous system
  • Neurobiology: the study of the cells of the nervous system, including their organization and interactions (e.g., synapses, functional circuits, etc.)
  • Neurophysiology: the study of the functioning of the nervous system
  • Neuropathology: the study of diseases of the nervous system by microscopic examination of nervous and associated tissues (e.g., meninges but also bone or muscle)
  • Neuropsychopharmacology: the study of the effects of drugs on behavior, mood, cognition, and other neurological functions
• Comprises numerous subspecialties such as:
  • Clinical neurophysiology
  • Vascular neurology
  • Neuromuscular medicine
  • Pain medicine
  • Sleep medicine
  • Neurodevelopmental disabilities and child neurology
• Since neurological symptoms (e.g., dizziness) are very common and their differential diagnosis can include potentially life-threatening neurological emergencies (e.g., stroke), all physicians should be familiar with the basics of neurology and know how to recognize manifestations of neurological disease.
• In turn, neurologists should be competent in a range of other medical fields, particularly in internal medicine and psychiatry, because diseases related to other specialties can have neurological manifestations and/or require a multidisciplinary approach.

What does a neurologist do?

• A neurologist is a medical doctor trained to diagnose and manage various neurologic disorders, including:
  • Seizure disorders and epilepsy
  • Movement disorders (e.g., Parkinson disease)
  • Neurocognitive disorders (e.g., Alzheimer disease)
  • Demyelinating disorders (e.g., multiple sclerosis)
  • Strokes and vascular disorders (e.g., vascular dementia)
  • Headache disorders (e.g., migraine)
• Neurological disorders in people younger than 18 years are typically managed by pediatric neurologists. Some of the conditions that affect the pediatric population include:
  • Cerebral palsy
  • Metabolic diseases (e.g., lysosomal storage diseases)
  • Epilepsy
  • Neurodevelopmental disorders (e.g., autism spectrum disorder)
  • Neuromuscular disorders (e.g., spinal muscular atrophy)
• Even as medicine becomes increasingly dependent on technology, neurologists rely heavily on a detailed history and neurologic examination, including testing of mental status, vision, speech, strength, sensation, coordination, reflexes, and gait.
• Neurologists are trained to interpret various tests to aid in the diagnosis, including neuroimaging (CT, MRI), electroencephalography (EEG), lumbar puncture (LP), and nerve conduction studies/electromyography (ENG/EMG).
• Neurologists use a variety of modalities to care for their patients. Although neurologists rely predominantly on medical management, they are also trained to perform various procedures including LP and ENG/EMG.
• Subspecialty-trained neurologists also perform intraoperative brain and spine monitoring, autonomic testing, endovascular procedures, botulinum toxin injections, and skin/muscle biopsies.

Clerkship structure

The length of the clerkship is typically 4 weeks, but varies from school to school. The rotation can comprise the following:

• Inpatient portion: visit hospitalized patients
• Outpatient portion: visit patients receiving medical treatment who are not hospitalized
• Additional sub-rotations:
  • Neurosurgery
  • Neuroradiology
  • Neurointerventional surgery (also known as endovascular surgical neuroradiology or interventional neuroradiology)

Clinical skills

General skills

Neurology clerkships are structured to give medical students a comprehensive understanding of the specialty, but they also cover a range of skills and tasks required for daily work in other specialties as well. Such general skills include

• Pre-rounding
• Rounding
• Writing patient notes
• Presenting patients
• Outpatient experience
• Writing orders

Neurology-specific skills

• Neurological examination: crucial for
  • Recognizing neurological deficits
  • Localizing lesions
  • Developing a differential diagnosis
• Interpreting neuroimaging studies (e.g., CT, MRI, angiography)
  • Recognizing radiographic features of various pathologies (e.g., strokes, tumors, trauma, demyelination, etc.)
  • Familiarizing yourself with neuroanatomy
• Having knowledge of the common medications used to treat various neurological disorders
  • Antiepileptics
  • Pharmacological treatment of dementia
  • Medication for Parkinson disease
• Surgical tasks
  • During your clerkship, you might be able to observe or participate in bedside lumbar puncture.
  • Some neurology clerkships include 1–2 weeks of neurosurgery.

Daily schedule

Inpatient service

• 06:00–08:00 a.m.
  • Pre-rounding
  • Sign-out of the overnight patients by the overnight residents/healthcare providers
  • Morning lectures
• 08:00 a.m.–noon
  • Rounds with the department's attendings, residents, and fellows.
  • Patient consultations
• Noon–01:00 p.m.
  • Lunch break and noon lectures
• 01:00–04:00 p.m.
  • Writing notes and receiving updates from consult teams
  • Discharge teaching for patients and their guardians
  • Conferences and lectures, including:
    • Grand rounds
    • Morbidity and mortality conferences
    • Core curriculum didactic activities such as lectures, case-based sessions, and seminars.
• 04:00–05:00 p.m
  • Evening sign-out

Outpatient service

• 08:00–08:30 a.m.
  • Arrive at the outpatient office whenever your preceptor’s first patient is scheduled to arrive
  • Review of patients' charts and history prior to visit
• 08:30–noon
  • Visit patients either by yourself or with your preceptor
  • History taking and physical examination of the ambulatory patients
  • Presentation of the patients to the attendings
  • Assistance with procedures during outpatient visits
• Noon–01:00 p.m.
  • Lunch break and noon lectures
• 01:00–05:00 p.m.
  • Afternoon patients consultation and examination
  • Finishing patient notes and/or teaching
  • Conferences and lectures

Evaluation and grading

• Varies among institutions but usually is pass/fail, and (typically) also high pass and honors. It consists of:
  • Clinical grade
  • Examination (usually shelf exam)
  • Possibly other assignments

AMBOSS study plans

AMBOSS has created study plans with recommended articles and questions for all clerkships and some subspecialties, including:

• Neurology: https://go.amboss.com/neurology ^[1]
• Ophthalmology: https://go.amboss.com/ophthalmology ^[2]

Objectives

After the neurology clerkship, students should be able to:

• Compile a detailed neurologic history and perform a comprehensive neurologic examination
• Present cases of newly admitted patients as well as summaries, updates, and trends in previously introduced patients
• Formulate differential diagnoses and plan further diagnostic steps
• Recognize neurologic emergencies (such as status epilepticus, myasthenic crisis, stroke) and initiate the treatment
• Know when to order a neurological consultation
• Formulate and discuss treatment options and present a treatment plan to patients and their families
• Furthermore, students should have:
  • Scientific and clinical knowledge of common acute and chronic neurologic disorders as well as preventive measures
  • Communication skills to engage professionally in conversations with patients and their families as well as colleagues and other house staff
  • Cultural sensitivity and ethical behavior to address patients appropriately in life-changing situations (e.g., before procedures or regarding end-of-life decisions)
  • Strategies for self-assessments and self-directed learning to recognize knowledge gaps and consult reliable resources

Pre-rounding

• See “Pre-rounding” in the ”Clerkship guide” article for more information.

Rounding

• See “Rounding” in the ”Clerkship guide” article for more information.

Writing notes

• It is beneficial to follow the SOAP (Subjective, Objective, Assessment, Plan) method for writing notes.
• Ask your attending and resident about the preferred note format
• Create templates for future notes to save time.
• See “Writing notes” in the ”Clerkship guide” article for more information.

Presenting patients

• Prepare an outline of the presentation after pre-rounding to stay organized.
• See “Presenting patients” in the ”Clerkship guide” article for more information.

Placing tentative orders

• Typically, you and your preceptor will put in orders together after seeing the patient.
• See “Placing tentative orders” in the ”Clerkship guide” article for more information.

Call duty

• See “Call duty” in the ”Clerkship guide” article for more information.

Attending meetings and conferences

• See “Attending meetings and conferences” in the ”Clerkship guide” article for more information.

History taking

• Some neurological patients will be sedated or comatose and will not be able to provide a history.
• See the ”Medical history” article for more information.

Physical examination

General principles

• See the “Physical examination” article for a general overview and techniques.
• For more details on specific examinations, see the following AMBOSS articles:
  • Head and neck examination
  • Cardiovascular examination
  • Pulmonary examination
  • Abdominal examination

Neurological examination

General considerations

• Neurological examination is the cornerstone of the neurology clerkship and should be done on every patient.
• In patients previously visited, any improvements and/or worsening of neurologic functions seen on the examination must be noted.
• Remember to consider both sides when assessing unilateral symptoms or findings (e.g., numbness of the left hand) as well as when performing routine examinations (e.g., checking reflexes). Asymmetry in neurological findings is always abnormal.
• See the articles on ”Neurological examination” and ”Mental status examination” for more information about the examination techniques.

Sequence

1. Mental status examination
   • Level of alertness
   • Language
   • Memory
   • Attention
   • Calculation
   • Visuospatial processing
   • Abstract reasoning
2. Cranial nerve examination
   • Vision
   • Light pupillary reflex
   • Eye movements
   • Facial sensation along with corneal and jaw reflexes
   • Facial movements
   • Hearing
   • Palatal movements and reflex
   • Neck and shoulder movements
   • Tongue inspection and movement testing
3. Motor examination
   • Muscle appearance
   • Tone
   • Strength
   • Pronator drift
   • Involuntary movements (e.g., myoclonus, tremor, dystonia)
4. Reflexes
   • Normal reflexes
     • Upper extremity: biceps reflex, triceps reflex, brachioradialis reflex
     • Lower extremity: patellar reflex and Achilles reflex
   • Abnormal reflexes (e.g., Babinski sign)
5. Sensory function
   • Elementary sensory modalities
     • Pain
     • Light touch
     • Temperature
     • Vibration
     • Joint position sense
     • Romberg test
   • Discriminative sensory modalities
     • Stereognosis
     • Graphesthesia
     • Two-point discrimination
     • Baresthesia
     • Double simultaneous stimulation
6. Coordination
   • Finger-to-nose test
   • Heel-knee-shin test
   • Rapid alternating movement test
7. Gait
   • Casual
   • On toes
   • On heels
   • Tandem

• Some typical question topics may be:
  • Neurological examination: procedures and clinical significance of specific findings (e.g., the difference between findings in upper motor neuron lesions and lower motor neuron lesions, patterns of sensory loss in different lesions of the nervous system)
  • Questions on neuroanatomy and localization of functions in the cerebral cortex
  • Management of stroke (e.g., indications and contraindications for thrombolytic therapy, the NIH stroke scale, etc.)
  • Delirium vs. dementia
• See “Clinical evaluation: how to impress your preceptors” in the ”Clerkship guide” article for more information.

1. Overview of stroke
2. Neurological examination
3. Meningitis
4. Seizure disorders
5. Multiple sclerosis
6. Brain tumors
7. Major neurocognitive disorder
8. Cranial nerve palsies
9. Parkinson disease
10. Neurocutaneous syndromes

General information

• The determinants of a clerkship grade vary both from school to school but generally consist of a mixture of the following criteria:
  • Performance evaluations by residents and attending physicians (50–75% of the grade)
  • Shelf exam (or similar exam) performance (25–50% of the grade)
• Top tips to impress your preceptors include:
  • Showing interest in the topic: even if you are not planning on going into neurology, ask questions to show interest
  • Knowing how to perform the neurological examination. Do not forget to bring the tools you need (ophthalmoscope, otoscope, stethoscope, high-intensity penlight, reflex hammer, 128 Hz tuning fork, safety pins, cotton, tongue depressors, and visual acuity card).
  • Studying your patients and being ready to answer questions about them.
  • Knowing the diseases that you are more likely to encounter during your rotation, including diagnostics and management.
    • This depends on the type of patients your preceptor is going to visit.
    • For example, if you are rotating in a stroke unit, be sure to know the NIHSS or your clinic's stroke workup.
• See “Evaluation and grading” in the ”Clerkship guide” article for more information.

Shelf exam

• For MD students, there is a standardized shelf exam offered by the NBME®.
• For DO students, there is not a dedicated COMAT neurology shelf exam from the NBOME®. Instead, neurology topics are part of the internal medicine shelf exam.
• For more information about the format of the shelf exams and tips for preparation, see “Exams: what to expect” in the ”Clerkship guide” article .

Format

• Evaluates a student’s mastery of neurology and its application when observing and diagnosing patients.
• Typically taken during the third year of medical school, after the neurology clerkship.
• Despite neurology clerkships being relatively short (4–6 weeks), the exam features particularly long and challenging stems that do not necessarily cover what comes up in rotations. With that in mind, students should start preparing as early as they can.

Significance

• Although not all students must take a neurology shelf exam, most medical schools have a required neurology clerkship.
• The NBME® exam
  • Can only be taken at authorized testing locations, like Prometric test centers or on campus at select medical schools.
  • It has a similar interface as the USMLE step exams, with most questions set up as a vignette.
  • Graded on a national average: the number of correct answers you get places you in a percentile, which is then measured across national grades
• Whether or not you pass your neurology clerkship depends on your medical school’s individual requirements.

Topics ^[3]

• General principles (including normal age-related findings) (1–5%)
• Behavioral health (3–7%)
• Nervous system and special senses (60–65%): some of the main topics include:
  • Infectious, immunologic, and inflammatory disorders
  • Neoplasms
  • Cerebrovascular disease
  • Disorders related to the spine, spinal cord, and spinal nerve roots
  • Cranial and peripheral nerve disorders
  • Degenerative disorders/amnestic syndromes
  • Neuromuscular disorders
  • Movement disorders
  • Sleep disorders
  • Traumatic and mechanical disorders
  • Disorders of increased intracranial pressure
  • Congenital disorders
  • Adverse effects of drugs on the nervous system
  • Disorders of the eye and ear
• Musculoskeletal system (10–15%)
• Other systems, including multisystem processes and disorders (15–20%)
• Social sciences, including death and dying and palliative care (1–5%)

Studying for the neurology shelf exam

• Work on how to quickly identify high-yield information in a question stem. It will help you move through the exam faster in the limited time available.
• Do not ignore complicated topics like vertigo; even if it is not always indicated as high-yield, it may appear several times.
• Practice analyzing laboratory studies and CSF results, and understand the differences between CT and MRI.
• Dedicate as much time as you can to memorizing neurology vocabulary, which is often complicated and specific.
• Go through as many neurology shelf exam practice questions as you possibly can, which studies have shown correlates with higher exam scores (AMBOSS currently has 350+ neurology-specific questions)
• There is some overlap between the psychiatry and neurology shelf exams, especially when it comes to drug-related questions, so it is a good idea to take them in succession, if possible.
• Master anatomy and neurological pathways, as lesion localization makes up a substantial part of the exam.

AMBOSS has created study plans with recommended articles and questions for all clerkships and some subspecialties, including:

• Neurology: https://go.amboss.com/neurology ^[1]
• Ophthalmology: https://go.amboss.com/ophthalmology ^[2]

Below, you will find a list of resources you can use to supplement your learning during the neurology clerkship. See “Resources” in the ”Clerkship guide” article for a comprehensive list of other resources you can use for all your rotations including neurology.

Reading material

• AMBOSS: offers a comprehensive library with over 100 neurology articles and more than 350 questions to help you prepare for your neurology shelf exam.
• Journals: The following journals have the largest impact factor in the field. Subscribe to the mailing list or add them to your RSS feed to receive the latest research and news.
  • Clinical
    • Lancet Neurology
    • Nature Reviews Neurology
    • JAMA Neurology
    • Neurology
    • Frontiers in Neurology
  • Basic and translational neuroscience
    • Nature Neuroscience
    • Brain
    • Journal of Neuroscience.
• NEJM Interactive clinical cases: A library with more than 60 clinical cases with teaching slides. Select “Neurology” in the filter list to access the neurological cases. ^[4]
• Guidelines from the neurological societies: See the list in “Neurological societies” below.

Neurological examination

• NeuroLogic: a guide to clinical neuroanatomy and neurological examination supplemented by videos and interactive cases ^[5]
• Neuroexam Online: a video library on neurological examination supplemented with the descriptions of technique and relevant neuroanatomy ^[6]

Neurological societies

• American Academy of Neurology (AAN)
  • Offers a free membership for students and interns
  • Contains a lot of useful information for clerkships
  • Provides guidelines for diagnostics and/or management of a range of neurological disorders
  • Has a large variety of podcasts and educational courses
  • Continuum is an educational journal of AAN that contains articles covering specific topics in neurology along with their audio versions (so you can listen to them on go).
  • Resident and Fellow Section of Neurology journal covers interesting neurological cases and provides teaching points for students and trainees.
• International Headache Society (IHS)
  • Hosts International Classification of Headache Disorders
  • Provides guidelines for diagnosis and management of different types of headaches
• Movement Disorders Society (MDS)
  • Has a large video library covering different types of movement disorders and an educational platform with courses ranged by difficulty
  • Provides guidelines for diagnosis and management of different types of movement disorders
  • Free membership for students
• International Association for Study of Pain (IASP)
  • Contains definitions and terminology used to report anything related to pain
  • Provides guidelines for diagnosis and management of different types of pain
• International League Against Epilepsy (ILAE)
  • Hosts definitions and classification of seizures and epilepsy
  • Provides guidelines for diagnosis and management of different types of seizure disorders
  • Has a teaching library that contains videos and EEGs of different types of seizures along with explanations
  • ILAE Young Epilepsy Section is a community of students, residents, and young neurologists and researchers interested in epilepsy.

Neuroradiology

• Radiopaedia.org: the largest compilation of x-ray, CT, MRI, and ultrasound images along with references on specific topics, including neuroradiology ^[7]
• Atlas Of The Brain by Dartmouth Medical School: hosts detailed guidance on gross and radiological anatomy of the brain ^[8]
• Atlas of brain MRI at w-radiology.com: a good introductory tutorial on brain MRI ^[9]

Calculators

• Examples of calculator apps you can use include QxMD and MDCalc
• Make sure you bookmark frequently used scores and scales such as:
  • Glasgow Coma Scale
  • FOUR Score
  • National Institutes of Health Stroke Scale
  • Expanded Disability Status Scale
  • Unified Parkinson disease rating scale
  • Modified Hoehn and Yahr Scale
  • Modified Rankin Score
  • Barthel Index
  • Modified Fisher Scale

• Neurology is a rapidly evolving clinical scientific field, closely connected to basic sciences such as neuroanatomy and neurobiology. Thus, there is a wide range of basic, translational, and clinical science projects for you to get involved with.
• Research opportunities can best be found by asking the attending physicians you worked with.
• If your attendings do not have any research opportunities available, you may ask them if they have any colleagues doing research they could put you in contact with.
• Most physician-researchers will be happy to have a medical student join their team.
• See the article “Residency applications” for more information on how to best prepare during clerkships, including recommendations for letters of recommendation (LORs) and gathering research experience.