The ultimate goal of the Neurology clerkship is to teach an approach to the neurological patient rather than a collection of facts. Accordingly, students should become comfortable in taking concise history, performing and interpreting a neurological examination. Next, through a logical, ordered process, they should be able to anatomically localize the site of neurological lesions and identify potential pathophysiologic mechanisms of dysfunction. Students will be exposed to diagnosis and treatment of major neurological diseases in both inpatient and outpatient settings. Critical areas in Neurology will be discussed in tutorial sessions led by attending neurologists and senior residents.
ON THE FIRST DAY OF THE ROTATION, PLEASE REPORT TO THE UNIVERSITY HEALTH CENTER, CROCKETT C OR D AT 8:00 AM, REGARDLESS OF HOSPITAL ASSIGNMENT.
Because students are distributed among a number of different hospitals, under the supervision of neurologists with distinctive teaching styles, the experience will vary according to placement. Students in community hospitals are expected to follow the patients of the private attending neurologist through both inpatient consultation and outpatient office visits. Students at the DMC hospitals will have a faculty attending neurologist as a tutor. They will be assigned to a senior resident-led team at either Detroit Receiving Hospital or Harper Hospital where they are expected to work-up and follow patients requiring neurological consultation or care. Students at the VA Medical Center will divide their time between Neurology Clinic, the consultation service and inpatient service. Modifications have been made to ensure an equivalent, although not identical experience among all locations.
EVALUATION AND FEEDBACK
The supervising attending or tutor will evaluate students with input from senior residents, when appropriate. When multiple neurologists participate in student supervision, the evaluators may submit a unified evaluation form with feed back from the senior resident.
At the end of the rotation, at the final exam and accompanying the answer sheet, students are required to complete an evaluation form. Students are asked to comment on any and every aspect of the course including house staff, attendings, hospitals and quality of teaching. Evaluations may be anonymous or signed, as long as the hospital is identified. The clerkship director reads each of these and in the past, when appropriate, has made changes in the course to correct deficiencies. Under no circumstances is primary data shared with either house staff or faculty. Confidentiality is sacrosanct and ensures an honest evaluation process. Composite evaluations may be made and used, however, if a consistent pattern emerges that requires correction. In addition, students will be given a general course evaluation developed by the Medical School for the entire clerkship experience.
A final examination is given at the end of each month. Dates and times will be announced at orientation. The examination is the Neurology Clerkship Subject Exam (SHELF), will consist of 100 multiple-choice questions and you will have 2 hours and 10 minutes to complete.
MINIMUM PROFICIENCY STANDARD - YEAR III STUDENTS
By the end of the clerkship, each student should be able to take an appropriate clinical history and perform a complete and orderly neurological examination as well as pertinent aspects of a general physical examination (e.g. carotidartery examination in a patient with a stroke). Students are expected to be able to localize the most likely site of the problem within the nervous system and to justify their opinion. Students are also expected to approach patients with appropriate sensitivity and to respect the patient’s dignity. There is a Neurology passport that must be completed by the supervising attending or the senior resident and must be returned at the end of the clerkship. (The clerkship will not be complete without returning this passport). The passport involves performing a history and a Neurological exam on a patient.
When multiple neurologists participate in student supervision, one evaluation form may be submitted after obtaining input from the supervising neurologists and the senior residents. Evaluations will consider a student’s participation in clinical rounds, presentations, neurological assessments, ethic, and student‘s interaction with patients, families, staff and team members. .
The clerkship director determines final grades with assistance from a grading committee consisting of the Departmental Chairman and Associate Chairman. All grades may be appealed to the committee.
Students receiving a failing clinical grade must repeat the course.
Students who receive a Satisfactory or honors clinical grade but fail the final examination will receive a grade of unsatisfactory and must retake the written exam. If a student fails the retake exam he/she must meet with the Clerkship director to determine the next step, as the student may have to repeat the clinical rotation. Students who fail the clinical rotation will receive unsatisfactory grade for the course and must repeat it.
Daily attendance is mandatory. No more than two days absence are permitted unless medically excused including a written explanation from a physician, or previously arranged with the attending physician with approval of the clerkship director. Extended absences must be made up or will result in an Incomplete clinical grade. Final decisions will be made by the Year III Neurology Committee.
GRADING CRITERIA AND FINAL GRADES
The SHELF exam began to be given instead of the departmental exam in 2004 - 2005; the grading of this test is determined by the mean and the standard deviations. The passing grade is the mean minus 1 ½ the standard deviation, and the honors passing grade is the mean plus one standard deviation. (The criteria are consistent with the SOM guidelines). If the mean of our students exceeds the national mean, then the national mean will be used in determining the grades following the above criteria.
Students receiving both an Honors clinical evaluation and Honors final exam grade will receive an Honors grade for the course.
Students receiving an Honors clinical evaluation and a satisfactory final exam grade will receive a course grade of Satisfactory with Commendation.
Students receiving a satisfactory clinical evaluation and an Honors final exam grade will receive a course grade of Satisfactory with Commendation.
Students receiving both a satisfactory clinical evaluation and satisfactory final exam grade will receive a satisfactory grade for the course.
CORE CURRICULUM GUIDELINES
Endorsed by the following organizations - October 2000:
- American Academy of Neurology
- Association of University Professors of Neurology
- American Neurological Association
Up to 10% of patients seen by family practitioners present with neurologic symptoms and pose neurologic questions to their physicians. Only 16% of the 45 million Americans who visit a physician for a chief complaint referable to the nervous system are ever evaluated by neurologists. Clearly, primary care physicians are routinely called upon to evaluate and manage patients with neurologic disease. Practicing physicians require a firm understanding of the general principles of clinical neurology. The most suitable setting in which to lay the foundation for that understanding is in a neurology clerkship in the clinical phase of medical school. This document outlines the desirable components of a clinical neurology clerkship.
Goals and Objectives of the Clinical Neurology Clerkship
To teach the principles and skills underlying the recognition and management of the neurologic diseases a general medical practitioner is most likely to encounter in practice.
To teach or reinforce the following PROCEDURAL SKILLS:
- the ability to obtain a complete and reliable history
- the ability to perform a focused and reliable neurologic examination
- the ability to examine patients with altered level of consciousness or abnormal mental status
- the ability to deliver a clear, concise, and thorough oral presentation of a patient's history and examination
- the ability to prepare a clear, concise, and thorough written presentation of a patient's history and examination
- [Ideally] the ability to perform a lumbar puncture
To teach or reinforce the following ANALYTICAL SKILLS:
- the ability to recognize symptoms that may signify neurologic disease (including disturbances of consciousness, cognition, language, vision, hearing, equilibrium, motor function, somatic sensation, and autonomic function)
- the ability to distinguish normal from abnormal findings on a neurologic examination
- the ability to localize the likely site or sites in the nervous system where a lesion could produce a patient's symptoms and signs
- the ability to formulate a differential diagnosis based on lesion localization, time course, and relevant historical and demographic featurese. an awareness of the use and interpretation of common tests used in diagnosing neurologic disease
- an awareness of the principles underlying a systematic approach to the management of common neurologic diseases (including the recognition and management of situationsthat are potential emergencies)
- an awareness of situations in which it is appropriate to request neurologic consultationh. The ability to review and interpret the medical literature (including electronic databases) pertinent to specific issues of patient care
- To teach or reinforce the following PROCEDURAL SKILLS:
Content of subjects to be taught
The Neurologic Examination (as an integral component of the general medical examination)
- how to perform a focused but thorough neurologic examination
- how to perform a screening neurologic examination
- how to perform a neurologic examination on patients with an altered level of consciousness
- how to recognize and interpret abnormal findings on the neurologic examination
Localization - general principles differentiating lesions at the following levels:
- Cerebral hemisphere
- Posterior fossa
- Spinal cord
- Nerve root/Plexus
- Peripheral nerve (mononeuropathy, polyneuropathy, and mononeuropathy multiplex)
- Neuromuscular junction
Symptom Complexes - a systematic approach to the evaluation and differential diagnosis of patients who present with:
- Focal weakness
- Diffuse weakness
- Involuntary movements
- Gait disturbance
- Urinary or fecal incontinence
- Vision loss
- Acute mental status changes
- Focal pain (facial pain, neck pain, low back pain, neuropathic pain)
- Numbness or paresthesias
- Transient or episodic focal symptoms
- Transient or episodic alteration of consciousness
- Sleep disorders
- Developmental disorders
Approach to Specific Diseases - general principles for recognizing, evaluating and managing the following neurologic conditions (either because they are important prototypes, or because they are potentially life-threatening):
- Increased intracranial pressure
- Toxic-metabolic encephalopathy
- Subarachnoid hemorrhage
- Status epilepticus
- Acute stroke (ischemic or hemorrhagic)
- Spinal cord or cauda equina compression
- Head Trauma
- Acute respiratory distress due to neuromuscular disease (e.g., myasthenic crisis or acute inflammatory demyelinating polyradiculoneuropathy)
- Temporal arteritis
- Alzheimer's disease
- Parkinson's disease
- Essential tremor
- Multiple sclerosis
- Bell's palsy
- Carpal tunnel syndrome
- Diabetic polyneuropathy
- Brain death
- Potential emergencies
- The Neurologic Examination (as an integral component of the general medical examination)