Neurology -- Correspondence for Moore and Chalk, 72 (23) 2020-2023

HOME

HELP

FEEDBACK

SUBSCRIPTIONS

Correspondence published:

The essential neurologic examination: What should medical students be taught?: Kimford J. Meador (22 July 2009)

Reply from the authors: Fraser Moore, Colin Chalk (22 July 2009)

The essential neurologic examination: What should medical students be taught? 22 July 2009

Kimford J. Meador,
Emory University
101 Woodruff Circle, Ste 6000, Mail Stop 1930-001-1AN, Atlanta, GA 30322
Send Correspondence to journal:
Re: The essential neurologic examination: What should medical students be taught?

kimford.meador{at}emory.edu Kimford J. Meador

Moore and Chalk compared neurologists and medical students on their perception of the “essential” components of the neurological examination for a common clinical scenario. [1] They asked their participants to decide which components of the exam should be included to confirm the impression that the patient is neurologically normal if the history suggests that the patient is unlikely to have abnormal findings on the neurological exam.
Responses were mostly similar across neurologists and students yet, surprisingly, no components of the mental status exam were mentioned. There are at least three concerns raised by these findings. First, there are several common disorders where the neurological exam would likely be normal but a mental status exam should definitely be included. A mental status exam could detect recent confusion, recent hemispheric transient ischemic attack, or new onset seizure disorder.
Second, the absence of any mental status examination in a listing of essential neurological exam components promotes the view that cognitive and behavioral assessments are not important or even common elements of the neurological exam. This approach might work in a neuromuscular clinic but would result in inadequate neurological assessments in a general neurological practice.
Third, the neurological exam varies widely by disorder (e.g., dementia vs. low back pain), and the exam is directed by the history. Thus, there is no single, essential neurological exam. Understanding how students apply the neurological exam is important, but the most critical factors are whether they can anticipate which components to apply from the history and whether they can perceive the patterns of abnormalities in the exam for common neurological disorders.
References
1. Moore FG, Chalk C. The essential neurologic examination: what should medical students be taught? Neurology 2009;72:2020-2023.
Disclosure: Dr. Meador serves on the editorial boards of Neurology, Cognitive and Behavioral Neurology, Epilepsy and Behavior, Epilepsy Currents, and Journal of Clinical Neurophysiology; performs mental status exams in his practice (2%) has received research support from Schwarz Biosciences, UCB, Myriad, Marius, Esai Inc., NeuroPace, and GlaxoSmithKline; has received funding from the NIH [#2RO1-NS38455 (Principal Investigator); # N01-NS-5-2364 (Consultant); # R01-NSO31966-11A2 (Consultant); #R44AG17397 (Co-investigator); and #RO1-NS-039466 (Co-Investigator)]; has received research support from McKnight Brain Institute (Co-investigator) and the Epilepsy Foundation (Co-investigator).

Reply from the authors 22 July 2009

Fraser Moore,
McGill University
3755 Côte-Sainte-Catherine E-005, Montréal, QC H3T 1E2 Canada,
Colin Chalk
Send Correspondence to journal:
Re: Reply from the authors

fraser.moore{at}mcgill.ca Fraser Moore, et al.

We thank Dr. Meador for his interest in our paper. Our objective was to determine why medical students frequently report a lack of confidence in performing the neurological examination. Our hypothesis was that it may be because they have difficulty deciding which of the many different elements of the neurological examination are important to test for a given patient. This indecision would then lead to a lack of confidence.
To test our hypothesis, we compared the self-reported practice of graduating medical students to that of practicing neurologists (“the experts”) for one specific clinical scenario. We agree with Dr. Meador that the actual elements identified as being “essential” by either group would vary depending on the clinical scenario. However, the goal of our study was not to define the one, essential neurological examination that applies in all situations but to see if the two groups responded differently to the specific scenario we presented to them.
We did not find major differences between students and neurologists, and concluded that the source of students’ anxiety with the neurological examination must lie elsewhere. As Dr. Meador points out, among the potential factors may be the ability of students to anticipate which components of the examination to apply based on a given history, or whether they can perceive the patterns of abnormalities in the exam for common neurological disorders. These and other responsible factors are worthy of future investigation.
Finally, Dr. Meador also expresses concern about the absence of a formal mental status examination from the elements ranked most highly by our participants. We did include several elements of a mental status exam among the 46 elements from which students and neurologists could choose including: the Folstein mini-mental status exam, tests of language, tests of praxis, drawing, and executive function. Neither students nor neurologists ranked these elements highly in our clinical scenario. However, this should not be interpreted as a general statement about the value of the mental status exam.
The objective of our study was to try to determine what students and neurologists actually do when faced by our study’s scenario. We agree with Dr. Meador that, in many other clinical situations, the mental status exam may be extremely important.
Disclosure: Dr. Moore has received clinic support from EMD Serono; participated in MS clinical trials sponsored by EMD Serono, Bayer, and Teva; received funding to attend meetings from EMD Serono, Biogen, and Teva; received consulting fees from EMD Serono, Teva and Bayer. Dr. Chalk serves as a member of the editorial board of the Canadian Journal of Neurological Sciences.