Demystifying neurology
BMJ 2002; 324 doi: https://doi.org/10.1136/bmj.324.7352.1469 (Published 22 June 2002) Cite this as: BMJ 2002;324:1469All rapid responses
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Like many doctors in training, I do find mastering neurology
examination quite daunting. I often wonder why this is so. I am glad that
Dr Menken raised the issue in BMJ. Of course, just like learning any
branch of medicine, learning neurology involves learning to recognize
different signs and symptoms. But why is learning neurology has always
been more problematic for trainees than other disciplines? I would like to
put forward a few hypotheses, hoping that someone can come up with a
solution.
Firstly, most signs in neurology are dynamic in nature and the success in
picking up these signs depends not only on the power of observation, but
also on skilful elicitation. For example, most medical students can easily
tell whether a patient is jaundice or not just by passive observation. On
the other hand, to recognize abnormal pupil reflex requires fine
coordination between simultaneous skilful presentation of appropriate
light stimulus and astute observation of pupillary changes in real-time.
Secondly, neurological examination often depends heavily on patient's
cooperation. Therefore good communication skill is vital.
Thirdly, neurological examination is 'holographic'. It covers almost every
part of the human body using a wide variety of examination techniques.
Some times we have to use our sense of sight, sometimes we have to use our
sense of touch; sometimes we have to perceive changes at a very small
scale like looking for eye signs and sometimes we have to recognize
abnormality at a very grand scale like gross gait disturbance. Thus when
we are performing neurology examination, we are constantly shifting our
attention in order to pick up all the clues.
Fourthly, our ability to put forward a neurological diagnosis depends not
only on identifying a collection of seemingly unrelated deficits, but also
on the ability to synthesize all our findings succinctly. In other words,
one has to progress from seeing patterns to seeing patterns of patterning.
I am not sure whether our current training is addressing these issues. But
I hope that a more methodical and thoughtful approach can improve the
quality of our training.
Competing interests: No competing interests
dear Editor,
As a SHO, having passed my MRCP exams recently
I felt confident about my neurology skills.But I soon realised all the
skills I had gathered attending exam courses (and seeing patients)would be
difficult to maintain as u hardly ever see much neurology in a District
general hospital.
The neurology examination does require a bit of co-operation by the
patient and in a busy take often just a
brief mention of "grossly intact" is all it gets.The fact that most of the
neurological diagnosis depends on imaging and sophisticated tests makes it
rhe domain of university hospitals.It also is not incorporated as part of
many medical rotations which is something that needs to be looked at.
Competing interests: No competing interests
THE FEAR OF NEUROLOGY
Very interesting and useful the opinion of Dr. Menken and the World
Federation of Neurology. An overview about the same kind of problems in
medical education in Brazil shows a real fear among medical students in
regard to Neurosciences, even in Internal Medicine Residencey
Programs. Only the students who want to go into the Neurology or
Neurosurgery fields reveal a different pattern of behavior. But they need
to review all the basics of Anatomy, Physiology and Pharmacology of Nervous
System. Neuropathology by itself continues to be like a ghost in a haunted
house. We have very explanations and efforts to modify this picture - but
the problems are persistent. Non-neurologists say that the
neurology/neurosurgery doctors are nuts,freaks and so on. Are we of our medical
field so strange to the others? Perhaps one of the responses is the fact
that in the general formation of physicians a lot of neuroanatomic and
neuroscience are given without the proper relationship with the exterior
world reality - the general practitioner prefers to lead neurological
patients to the specialist, even in the more common and simple
situations, like migraine, a single generalized convulsion or the first
measures in neurotraumatology. Where and how have we neurologists failed ?
Competing interests: No competing interests