How to Collaborate Effectively with Your Attending Neurology Edition

How to Collaborate Effectively with Your Attending: Neurology Edition

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Welcome to Neurology! Get ready to “localize the lesion” and add a bowtie to your wardrobe. Your neuro clerkship will offer you the most variety in day-to-day learning opportunities. From stroke activations and procedures to clinic consultations, there’s something for everyone. It’s a rotation where you’ll learn skills to apply to any other field of medicine you eventually choose to practice. After all, anyone with a brain can have a seizure or a stroke!

Note that while you might be the brightest student in your class, gaining a solid grasp on interviewing a patient, performing a focused yet thorough enough physical examination to reach a decent differential diagnosis, and formulating a cost-effective, patient-centered plan of care will set you apart from your fellow medical school graduates as you go on to apply for residency. The neurology clerkship is unique because your experience will differ from institution to institution. Maybe your training hospital has a Neuro-ICU; maybe where you’re rotating, there’s an epilepsy monitoring unit. Maybe you’ll get to see patients in a clinical Center of Excellence. Even in smaller community hospitals, you’re guaranteed to encounter a unique chief complaint daily during this rotation.

A child with neurofibroma on their back.

A foundational skill to develop during this rotation is a thorough neurological examination, including giving a general exam and doing examinations of the HEENT, cardiopulmonary, gastrointestinal, dermatological, psychiatric, and, in select patients, genitourinary systems. Many neurological conditions affect other organ systems, and the degree of severity of different organ system dysfunction may result in neurological sequelae. For example, neurocutaneous disorders, like neurofibromatosis or tuberous sclerosis, feature many dermatological abnormalities, which can be supportive clues to the differential diagnosis. Mastering these examinations will not only make you feel prepared but also competent in your role on the care team.

Following a general examination, the neurological examination has distinct components that neurology attendings expect to hear in a specific format. These include mental status, cranial nerves, motor and sensory exam results, reflexes, coordination, and gait. A neurology attending will be wholeheartedly unimpressed if you say you “couldn’t get an exam” on an uncooperative or comatose patient. Consider the following report: did I have to lay hands on the patient to be able to relay the following?

“The patient is somnolent, without spontaneous speech (mental status exam). There is a brief eye-opening to voice; eye movements are grossly conjugate in all directions without nystagmus. Facial symmetry is normal. Hearing is grossly intact to voice. With yawning, the uvula and tongue are midline with symmetric palatal rise. There is no fixed head deviation (cranial nerve exam). Normal muscle bulk throughout. Brief antigravity movements of all four limbs are noted (motor exam). Sensation is intact to light touch throughout, as evidenced by withdrawal from nursing care (sensory exam). No spontaneous clonus (reflexes). No resting tremor (coordination).”

Practice on family members, friends, or fellow students to perfect your neurological examinations. A word about pediatric patients: You’ll rarely get to examine them in the order you’ll present the information to your attending. Much of the examination will occur through observation. Historically, the neurological examination was the only tool we could rely upon to localize the lesion or identify the problem for our patients. Those who came before us depended on excellent physical examination skills to determine the plan of care. Now, in the era of advanced neuroimaging, electrodiagnostic studies, genetic testing, and telemedicine, it may seem as if the physical examination is becoming obsolete. However, understanding the significance of physical exam findings helps narrow the neurodiagnostic evaluation, spares patients time and money, and avoids burdening our healthcare system.

Regular review of the functions of each cerebral lobe, cranial nerves, spinal cord pathways, peripheral nerves, and muscles will help you localize the lesion. If you’re a visual learner, you might need to bust out those old Netter’s flashcards! Keeping those in your pocket or using quizzing apps like Osmosis on your smartphone can be helpful for slow times on the wards. Gathering easy-to-read clinical vignette resources like Case Files, BluePrints, or PreTest can help you refamiliarize yourself with common neurological conditions and help with differential diagnosis generation. I do recommend The Little Black Book of Neurology for quick reference. Your attendings will be impressed if you have some awareness of current clinical practice guidelines. The American Academy of Neurology has excellent online resources, as does its publication, Continuum. Your neurology attendings undoubtedly subscribe to periodicals like Neurology in Clinical Practice, Brain and Life, and Practical Neurology. Along with easy-to-read short pieces, they can help keep you up-to-date on emerging research.

While on your neurology clerkship, a little enthusiasm goes a long way. Being proactive in discussions will help set you apart. Even if you’re not directly involved in the patient’s care, at least spend a few minutes researching their diagnoses and the common evaluation and management strategies before rounds. Be attentive during rounds and consultations, and for goodness’ sake, put your phone away! It’s better to keep a little notebook in your white coat pocket to jot down things to look up later than to be scrolling in a patient’s room or while your peer is presenting a patient. Remain an active listener, especially if it’s not your patient, but don’t overshadow your peers while they’re presenting. Nobody likes a show-off. If you know the answer but the student or resident being quizzed doesn’t, bite your tongue (stay quiet). If the attending opens it up to all, practice humility.

A care team listens to a medical student answer a question during rounds.

As you start interviewing patients, make sure to introduce yourself and explain your role on their care team. It can be awkward, but it’s important the patient understands your role. I’d recommend saying, “Hello! I’m student doctor so-and-so,” or “I’m the medical student on your team, and I’m here to gather your history and perform your physical examination so we can figure out how to help you.” That way, nobody will be confused. During your interview, show empathy and provide reassurance. Patients want to be heard and have their concerns validated. Statements like, “That sounds like it’s been hard for you,” or “That would be a lot for one person to deal with” help to relay empathy. Be cautious of patients with a pan-positive review of symptoms or the grocery list of medical complaints. If your time is short, acknowledge their concerns and ask them to pick their top three.

With medical interviewing, it’s important to practice explaining medical terms in layman’s language. I practice explaining common neurological issues to my non-healthcare family and friends and try to develop easily relatable analogies. Drawings can also be helpful. Do not provide medical advice without consulting with the rest of your supervisory team.

While in the clinic and on the wards, volunteer for tasks and express interest in procedures. Don’t be above the scut work. Sure, that’s not what you’re there for, but none of us are, and the work needs to get done. However, don’t turn yourself into an errand page or personal assistant. If you’re not interested in procedures, thank your resident or attending physician for the opportunity, suggest a peer who may want to get in there, and ask to stay and watch instead. Get to know the ancillary team members; learn their names. If there’s downtime, consider shadowing these team members, like speech pathologists or physical therapists. Demonstrating you can be an effective member of a multidisciplinary team is a valuable skill. Consider proposing to prepare a five-minute presentation on a diagnosis the team considered or encountered during rounds.

The neurology clerkship offers some unique procedural opportunities, like lumbar punctures, nerve conduction studies, and electroencephalograms. The electrodiagnostic technicians are often happy to have you shadow them. Consider visiting the emergency room or a clinic where lumbar punctures happen more frequently, like in Oncology for intrathecal chemotherapy. Use online tutorials and simulation labs; there are some great videos on YouTube. Review educational videos and practice on models; this is especially helpful for electromyograms, botulinum toxin injections or nerve blocks, and lumbar punctures. If you really want to understand what your patients go through with these tests, ask one of the technicians to hook YOU up to the EEG machine or test your nerve conduction. It will help you develop empathy as you counsel your patients about the procedures.

It’s highly improbable that you’ll encounter every diagnosis that could appear on your shelf exam while on your neurology clerkship. So, make sure to make time to study. Create a study plan that works for you, ideally aligned with the clerkship timeline. For example, if you’re on the stroke alert team for the first week, study the various types of strokes, their causes, and the most common interventions. Integrate review sessions, practice exams, and case studies. Focus on high-yield topics for the shelf exams. Your residents can help you prioritize. After all, they’ve taken those tests already! Use practice questions and exams for self-assessment. A word of advice: read the final sentence of the question stem first. You’ll save yourself time if you know what they’re looking for from the start.

You’ll do great if you employ even one of these techniques during your neurology clerkship. Remember to have fun; this is a unique opportunity to learn about rare, obscure, and interesting disease processes. Be prepared, act engaged, and read.

Good luck with your clerkships, and make sure to let us know if this blog helped you during your rotations in the comments below!

About the Author

Britton Zuccarelli, M.D., is a content writer for Osmosis from Elsevier and a pediatric neurologist and Associate Professor of Pediatrics at the University of Kansas School of Medicine. She completed her undergraduate degree at Cornell College, her medical degree from University of Kansas School of Medicine, and her residency in child neurology at Children’s Mercy Hospital. At the Salina Regional Health Center (SRHC), she serves as Medical Director for both the Concussion Program and the Infant Child Development Program. Dr. Zuccarelli is President of the Saline County Medical Society, a Fellow of the Child Neurology Society, and a member of the American Academy of Neurology and the American Epilepsy Society. In addition, she participates in the SRHC Strategic Planning Committee, SRHC Stroke Peer Review Committee, and SRHC Pediatric Subsection Committee. Dr. Zuccarelli is an American Heart Association Pediatric Advanced Life Support Instructor, is bilingual, and an avid researcher in neurogenetics. In her free time, she enjoys outdoor activities with her husband Jordan, a physical therapist, and their three children.


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