While rotating on the Neurology Services, you are responsible to participate fully in the team activities. Try to practice your H&Ps with first time patients and follow a minimum of four patients during your clerkship. You will be observed and evaluated by faculty, fellows, and/or residents. These assessments are based on the six ACGME Core Competencies:
- Medical Knowledge: knowledge about different neurological conditions, especially those commonly seen in the clinic or inpatient service.
- Professionalism: respectfulness, work ethic/dependability, motivation and excellence, honesty
- Patient Care: history taking, physical exam, clinical reasoning
- Practice-Based Learning: seeking feedback, intellectual curiosity, eagerness to learn, application of EBM, teaching others
- Interpersonal & Communication Skills: rapport with patient and family, oral presentations
- System-Based Practice: helpfulness to the team
The Neurology Clerkship Feedback & Clinical Evaluation Form will be used to grade these six Core Competencies. These evaluations will be completed online (New Innovations) by the faculty, fellows and/or residents that worked with you. You will receive a minimum of 4 evaluations. You can find these evaluations online or attached on the welcoming email. The Evaluation Forms comprise 45% of your total clerkship grade.
During the clerkship you need to complete two (2) Neurology Clerkship Bedside Skills Evaluation Forms. These evaluations should be done with a neurology faculty and can include an inpatient or outpatient (clinic) case. The aim is to assess your clinical skills via direct observation in 4 major categories: history gathering, neurologic examination, humanistic, professional qualities and presentation and clinical reasoning skills. The first evaluation should ideally be completed during the 2nd week and the last evaluation during the 4th week of the clerkship.
The intent of the portfolio is to ensure a well-rounded education experience as well as evaluate your medical writing abilities. The following required items are intended to assist in the development of your medical skills and medical writing by providing opportunities to practice newly acquired skills and attain feedback on your progress. PDF formats of the evaluations listed below are provided at the end of the syllabus, online, and attached on the welcoming email.
- Practice Based Learning (PBL) Write-Up:
Practice Based learning exercise (PBL) (for Gainesville rotators): While on the Gainesville neurology clerkship, you are required to present a Practice Based Learning exercise. A patient that you admitted (or followed) serves as the case on which you will base your PBL. You should develop a clinical question from the case, something not taught during the clerkship and which would make a difference in patient care. You should do a literature research and discuss 2-3 papers related to that question. The discussion should focus on the questions evaluated on the PBL subitem of the PBL Evaluation Form. This must be presented using a PICO model as a PPT presentation during the last week of the clerkship on the small group meetings. Start by briefly describing the case and then focus on your topic discussion. The presentation should be limited to up to 15 minutes. Don’t need to cover everything, pick only one aspect of the disease you would like to present (e.g. disease modifying therapies in Guillain-Barré; secondary prevention in Stroke, etc). The clerkship director will grade the PBL presentation using the Practice Based Learning Evaluation Form .
Please upload your PPT presentation to CANVAS assignments by the end of the clerkship. Delayed submissions will count against professionalism evaluation (reduction of 10% of the final grade). Lack of submission by the end of the clerkship will result in an “Incomplete” grade, which will require remediation (repeating the clerkship).
Practice Based Learning Exercise (PBL) (for Jacksonville rotators): While on the Jacksonville neurology clerkship rotation, you will be required to submit a written PBL exercise on a patient whom you have cared for during the rotation. This exercise will assess your ability to write a quality H&P, create a detailed yet pertinent list of neurologic localizations and differential diagnosis, and devise a management plan. In addition, the exercise will also assess your ability to ask pertinent questions that further the understanding and management of the disease condition, review and evaluate the existing literature, identify potential gaps in knowledge, and apply what your learned to the case at hand. A sample PBL will be included in your packet. The clerkship director will grade the PBL presentation using the
- Abnormal Physicial Finding Checklist: Please complete the Neurology Clerkship Abnormal Physical Finding Checklist form to document that you have seen all of these important neurological physical findings. Notify the clerkship director if you have not seen all of them. Watching a video or picture of the physical finding also qualifies as a positive observation. Please return the form to the clerkship coordinator for placement in your portfolio.
Helpful online resources to watch and learn neurological examination with videos:
https://www.youtube.com/playlist?list=PLHdemSStztKaB0A_iqfdiepvRwljoI1dF (University College of Dublin Neurology)
http://headneckbrainspine.com (Neuroanatomy imaging)
http://webeye.ophth.uiowa.edu/eyeforum/ (Iowa Eye Forums)
https://www.youtube.com/channel/UCcFOPnIMW5NtPKJAR0fDxkw/featured?disable_polymer=1 (Rutgers RWJMS Neurology teaching videos).
https://www.youtube.com/channel/UCvITX2Rdq4yx0GGos954tQw (Brain Pods neurology clerkship)
http://www.med.umich.edu/lrc/neurologic/ (UMichigan Neurologic localization)
https://www.movementdisorders.org/MDS/Education/Latest-E-Learning.htm (movement disorder societ e-learning, some free content available for non-members)
https://learning.aan.com/diweb/catalog/t/44187?_ga=2.133199886.1431055471.1557490635-463075479.1557490635 (AAN Neurobytes. Needs AAN membership (free for medical students)).
- American Academy of Neurology online Self-Assessment Examination (SAE): you will receive a code/link to access the AAN online SAE for medical students. This will allow you to practice NBME style questions, test your knowledge and get automatic feedback. All students should complete the online practice test which has been paid for by UF COM. This does NOT count for your final grade but it is expected to improve your NBME score.
- Status Epilepticus Simulation: The students will participate in a simulation of status epilepticus using the SinMan 3G mannequin. This activity aims to assess knowledge, leadership, teamwork, and communication in the management of status epilepticus. The students can read the material posted in CANVAS to prepare for the simulation. At the end of the activity, there will be a debriefing session. This activity is not graded. We value your feedback at the end of the simulation.
- Acute Stroke Simulation: The students will participate in an acute stroke simulation using the SinMan 3G mannequin. This activity aims to assess knowledge, leadership, teamwork and communication in the management of acute stroke. The students need to read in advance about the management of acute ischemic and hemorrhagic stroke. This activity is not graded. We value your feedback at the end of the simulation.
- Clerkship Evaluations: Help us make this the best Clinical Clerkship! Although not graded, we expect you to complete 5 evaluations by the end of the clerkship. These evaluations include one program/clerkship director evaluation and at least 4 faculty, fellow, resident evaluations.
All students will take an online NeuroCaRE Canvas Quiz with 4 clinical case vignettes and 3 questions for each case. This test evaluates the clinical reasoning and thinking process based on history and exam findings and the approach to differential diagnosis and treatment options for each case. The questions may include images and videos of exam findings. The questions are “essay type” and the student needs to type his/her answer with explanation/reasoning behind it (not a multiple-choice test). The test will occur on the afternoon of the day of the NBME test, from 1pm-2:30 pm (90 minutes total) at the same location as the NBME test. Passing score is ≥60% of total points available. Students who fail this exam receive an “Incomplete” as their final grade and will be required to re-take the exam. Failing the NeuroCaRE exam a second time will require repeating the neurology clerkship.
The topics included in the exam are part of the AAN Core Curriculum guidelines for a neurology clerkship experience:
A systematic approach to the evaluation and differential diagnosis of patients who present with:
- Acute, subacute, or episodic changes in mental status or level of consciousness
- Gradual cognitive decline
- Headache or facial pain
- Neck or back pain
- Blurry vision or diplopia
- Dysarthria or dysphagia
- Weakness (focal or generalized)
- Involuntary movements
- Numbness, paresthesia, or neuropathic pain
- Urinary or fecal incontinence/retention
- Unsteadiness, gait disturbance, or falls
- Sleep disorders
Approach to specific conditions:
General principles for recognizing, evaluating, and managing the following neurologic conditions as important prototypes, or potentially disabling or life-threatening conditions:
- Conditions that require prompt response
- Acute stroke (ischemic or hemorrhagic) or TIA
- Acute vision loss
- Brain death
- CNS infection
- Encephalopathy (acute or subacute)
- Guillain-Barre syndrome
- Head trauma
- Increased intracranial pressure
- Neuromuscular respiratory failure
- Spinal cord dysfunction
- Status epilepticus
- Subarachnoid hemorrhage
- Alzheimer disease
- Bell palsy
- Carpal tunnel syndrome
- Essential tremor
- Headache (tension, migraine, cluster)
- Multiple sclerosis
- Myasthenia gravis
- Parkinson disease
- Polyneuropathy, radiculopathy, motor neuron disease
22 yo woman that comes today for evaluation of headache. She says she started having headaches 6
years ago, initially only during her menstrual period, but now more frequently up to 3 weeks per month.
Headache is located on the right or left side, throbbing, can be up to 9/10 intensity with photophobia, phonophobia, nausea and vomiting. Headache lasts up to 6-8 hours, and sometimes even a whole day. Sleep relieves the headache but not all the time. Neurological examination is normal. She has history of asthma and kidney stones.
What other details in history would be important to ask in this case? (That may affect the way you treat).
What treatment would you suggest for her? Why?
Does she need head imaging? Explain
You are called to the ER to evaluate a 67 yo man with altered mental status. Patient was found unconscious by EMS and there are no relatives or history. On exam, patient is unresponsive and vitals are stable. Patient has his eyes closed, does not answer questions or follows commands. Corneal reflex is present. He has eye deviation to the right, slight right side of the lip twitching and right hand tremor. No response to pain in any of the 4 limbs, or to sternal rub or supraorbital ridge pressure. Deep tendon reflexes are 2+. Babinski is negative.
What is your differential diagnosis? Start with the most likely diagnosis.
What work up would you order in this case?
Discuss treatment options, in order of importance for this case.
The efforts on the NBME shelf exam comprise 25% of the total Neurology Clerkship score. There is not a minimum exam pass score for the clerkship. However, students who score below the 5th percentile nationally (65) need to meet with the clerkship director to discuss whether a test taking remediation plan should be developed to promote improved performance on subsequent NBME exams including Step 2. Shelf exams are usually scheduled on the last Thursday/Friday of the Clerkship.
To prepare for the shelf exam, we recommend the following resources based on clinical questions and common neurology cases:
- Case Files
- First Exposure to Neurology
- GunnerGoggles Neurology Shelf Review
- AAN NeuroSAE (you will receive a link)
- CANVAS modules: log in to CANVAS neurology clerkship page to access ppt and pdf presentations, videos and book chapters relevant to neurology
Other resources to help you not only prepare for the shelf, but to improve your general knowledge in Neurology, include:
Victor and Adams, Companion Handbook to Principles of Neurology and Principles of Neurology
Victor and Adams in Harrison’s textbook Principles of Internal Medicine
Greenberg, Aminoff and Simon, Clinical Neurology
Joynt’s Clinical Neurology (available in the Gainesville Neurology Library and on CD on the residents’ computer in Gainesville)
You may also find the textbook and notes from your Neuroscience course especially helpful. We want you to excel in this area so if you are feeling underprepared or overwhelmed, let us know! We are here to help.
The final grade of the Neurology Clerkship Program is determined by the outcomes of these five sections: Core Competency Evaluations, Bedside Skills Exam, Portfolio Compilation, NeuroCaRE and Medical Knowledge Examinations.
Total Grade (100%) = Competency Evals (40%) + BSE (10%) + Portfolio (10%) + NeuroCaRE exam (15%) + NBME Exam (25%)
Students with Professionalism concern will achieve a maximum grade of B+.
Students must satisfactorily complete all required components of each clerkship. Students who do not obtain a passing score will receive an incomplete grade (H) for the clerkship until all components are satisfactorily completed. Students with an unsatisfactory performance in any area should discuss the process and timing of remediation with the clerkship director. In general, failure on an exam is remediated by retaking the exam and achieving a passing score. Failure in the retaken exam will require repeating the clerkship. Failure to satisfy a clinical or professionalism component is remediated by the satisfactory completion of an individualized plan of remediation. This remediation is proposed by the clerkship director and approved by the Academic Status Committee.
Medical students may appeal a final grade or evaluation based on concerns about discrimination or the process used to assign the grade. The process is as follows:
- The student submits his/her written concern(s) about a final grade or evaluation and arranges a meeting to discuss the concern(s) with the respective course/clerkship director within one month of the posting of that grade.
If the student is not satisfied with the outcome:
- The student may submit their written explanation of the grievance to the Grade Grievance Committee consisting of the Chair of the Clerkship Committee, or designee if it involves his/her clerkship, and three faculty familiar with the medical education program who are not involved in the same course/clerkship as the grievance, or are members of the ASC. A 4th year medical student from the ASC will serve as a non-voting member on the Grade Grievance Committee. The faculty members of the Grade Grievance Committee are appointed by the Associate Dean of Medical Education.
- After review, the Grade Grievance Committee will submit a recommendation to the Associate Dean for Medical Education and the Chair of the Academic Status Committee who will review the report and provide the response to the student.
- The decision of the Associate Dean for Medical Education and the Chair of the Academic Status Committee is final.