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Neurology Clerkship

Leopold J. Streletz, M.D., Clerkship Director
Deema Al-Sheikhly, MRes, Clinical Curriculum Coordinator
Yoga Hassan, Clinical Curriculum Assistant

The neurology clerkship is a four-week required clinical rotation. Clinical neurology is by no means esoteric in any way, and the core knowledge taught in this clerkship is important in the every day practice of most physicians, regardless of specialty. Neurological emergencies like seizures, strokes, coma and spinal cord compression are common and you will certainly encounter them in your career. On the other end of the spectrum, routine neurological problems like headache, back pain, cognitive difficulties and weakness are very common and all physicians should have a basic understanding of the workup and treatment of these conditions.

If we can impart any advice, it is not to get behind. The course is only four weeks in length and there is a great deal of information to synthesize. Start reading on day one, and you will be in good shape. Our educational philosophy is not to teach or learn by rote memorization, but by integration of newly acquired facts into a preexisting framework of knowledge. Getting the “big picture” is much more important than the ability to memorize a random list of facts which will be quickly forgotten. The method of neurology is organized and involves stepping back and summarizing the case then answering some basic questions before generating long lists of differential diagnoses.

We recognize that most students do not select neurology as their eventual career. However, for those who are even only slightly considering the specialty, we encourage you to take this opportunity to speak to as many faculties as you can to find out more about this wonderful career. Make connections early in your career. Find a faculty mentor, or ask us to help you find one who shares clinical or research interests. This clerkship provides an opportunity to work with faculty members who may be able to write letters of recommendation for residency applications or involve you in a new or ongoing research project. Don’t stand in the background and expect these things to fall in your lap. The best advice is to be proactive and express your interest in the field.

This is a clinical clerkship, with daily patient exposure. Therefore, we ask that you dress professionally every day. This includes always wearing a short white coat. Scrubs are permitted, only when on call. Students should have the following instruments with them:

• Penlight
• Stethoscope
• Reflex Hammer
• 128 Hz Tuning Fork for vibration testing
• Ophthalmoscope
• Visual acuity testing card
• Tongue depressors
• Cotton swabs

The easiest way to fail this clerkship is to demonstrate a poor attendance record. The clerkship is only 4 weeks in length, which translates to 20 weekdays. No unexcused absences are permitted. Students may have two excused absences for medical illness with proper documentation. Please notify the clerkship coordinator, director and attending Neurologist about any planned or unplanned absences. Family emergencies should be discussed directly with a member of the clerkship leadership. Should a student have an unexcused absence, or more than 2 excused absences, they must be made up by taking an extra weekend call during the course. We are very serious about this issue, and have no qualms about enforcing this rule, even if it holds up a student’s graduation.

The Neurology clerkship is offered at one site: Hamad General Hospital (HGH).

The Neurology service at HGH is primarily consultative. Each student is expected to follow 2-3 patients at any given time. The number of patients is ultimately at the discretion of the attending physician. Students should pre-round on their patients and are expected to present any new admissions or consults they worked up at attending rounds. At HGH, rounds begin at 7:30am. The schedule of activities at HGH will be reviewed by HGH staff upon arrival of the student(s) assigned to each rotation.

Students will be rotating through two clinical rotations on a biweekly basis (see Rotation Schedule) over the term of the clerkship. They are:

• Neurology Service – Combined Consult and Ambulatory Services
• Neurosurgical Service – Primarily Inpatient Neurosurgery

This is the primary rotation of the service. The Consultant Attendings rotate on a weekly schedule. Students on-rotation will identify or be assigned new admissions and consultation which they will work-up and follow. They are expected to participate in the morning rounds and present completed write-ups on rounds and in conferences from time to time. They will be responsible for conducting the Professor rounds conducted at the end of each rotation. They should follow their patient’s progress and observe and participate in procedures performed on them whenever possible.

The neurology clerkship is primarily designed to provide training in inpatient Neurology. However, we recognize that much of neurology is ambulatory-based and consultation. Therefore, each student is expected to attend one morning or afternoon neurology clinic daily on the rotation. Ideally, the student should independently evaluate one new patient each day and then present the patient to the Neurologist attending. In addition, if a student has interest in a particular subspecialty area (stroke, pediatric neurology, or epilepsy), he or she can attend this clinic during the rotation with the clinician involved. Please arrange this directly with the involved attending physician. For those interested in more outpatient neurology exposure, fourth-year elective rotations will be available and details will become available.

The Neurology Rotation involves exposure to a wide range of neurodiagnostic procedures (EEG, EMG, NCS, and Evoked Potentials) commonly employed in clinical practice. Such cases usually involve neuromuscular disease and contrasts with the clinical spectrum encountered elsewhere in the clerkship. This segment of the rotation will be directly supervised by the HGH attending and the Clerkship Director

On the Neurosurgical rotation the Neurology Clerk will participate in the ward activities of a busy Neurosurgical Service. It is intended to provide needed exposure to intracranial hemorrhage, craniocerebral trauma and diseases of the spinal cord and roots. These diagnostic entities are rarely encountered on the medicine service but are neurological diseases with neurosurgical treatment. Students will be expected to continue to participate in the inpatient activities as on any service. They will be given an appropriate case to work-up and submit to the Neurosurgical attending. If the selected patient is operated on during the term of the neurosurgical rotation they may, with the permission of the involved attending, follow the patient to the operating theater and observe the procedure (no scrub-ins).

Neurology Morning Report (7:00AM) – Daily 3rd floor, HGH
Neurology Radiology Conference: Sundays (7:15AM) – MRI Conference Room, HGH
Neurology Conference: Sundays (8:00 AM) – Conference Room, HGH
NS/ICU Teaching Round: Monday (9:00 – 10:30AM) - SICU
Joint Neurosurgery/Radiology Conferences: Monday (1:00-2:30PM), MRI Conference Room, HGH
Neuropathology Meeting (CPC format): Monday (9:30-11:00AM) (biweekly) Pathology Dept HGH

All above activities are part of the Neurology Medical Student core curriculum. These are generally high quality conferences required for students.

Each student is required to take four weekday calls and one weekend call, Weekday calls should be taken once per week. They begin at 5:00PM and end at 10:00PM. Weekend calls are taken on Fridays or Saturdays from 8:00AM to 7:00PM. Students are expected to independently evaluate at least one patient per call. Calls should be logged on the clerkship card, with the signature of the attending who supervised the call.

In addition to the Neurology conferences, a specific set of conferences has been designed for medical student education in Clinical Neurology. These will consist of a series of live lectures, VS lecture, or live-video conferences with Dr. Safdieh (WCMC-NYC). Attendance at these conferences is mandatory. The conferences are designed to provide students with a framework for the study and practice of Clinical Neurology. Focus is placed on teaching methods of approaching neurological disorders. The sessions are interactive and student participation is very important. Therefore, advance preparation for the conferences is necessary. Each conference has a topic, with a specific set of goals and objectives, which are listed in this manual.

The Neurology medical student core curriculum takes place every Monday, Tuesday and Wednesday afternoon from 3:00-5:00PM and the schedule is as follows:

• Week One
  • Neurological Method
  • Headache
  • Cerebrovascular disease
• Week Two
  • Clinical Approach to Weakness
  • Neuro-infectious diseases
  • Seizures and Epilepsy
• Week Three
  • Delirium and Dementia
  • Movement Disorders
  • Multiple Sclerosis
• Week Four
  • Pediatric Neurology
  • NeuroEthics
  • Review of Clinical Cases

These conferences cover some very important topics in Clinical Neurology. As this is a clinical clerkship, the conferences are of a very clinical nature. Recall, however, that clinical neurology does not stand alone. It is well grounded in its underlying sciences, including neuroanatomy, neuropharmacology, neurophysiology and neuropathology. All of these topics were covered in depth in your Brain and Mind course. Understanding the principles of these subjects is very important in developing an understanding of Clinical Neurology.

As part of the didactic curriculum for the clerkship, the faculty of the departments of Neurosurgery and Pediarics has added several lectures. A specific schedule of times and location is distributed on the first day of the Clerkship. The topics may include Epilepsy Surgery, Brain Tumors in adults and children, Carotid Artery Disease, Disorders Cervical and Lumbosacral spine and Neurodevelopmental disorders. These lectures are mandatory.

Students will meet as a group with Dr. Streletz on Sunday and Thursday at 11:30 AM on the 3rd floor HGH. One student will formally present a patient and the group will then see the patient together. The attending physician must assist in the selection of the patient.

Students are required to submit three formal write-ups in order to successfully pass the clerkship. These should be organized, and contain an academic discussion. Write-ups must be handed in to the attending that evaluated the patient with you.

Write-ups should conform to the following format:

• Chief Complaint
• History of Present Illness
• Past Medical/Surgical History
• Medications and allergies
• Family History
• Social History
• General medical examination
• Neurological examination
  • Mental Status
  • Cranial nerves (listed individually)
  • Motor
  • Sensory
  • Deep tendon reflexes
  • Gait and coordination
• Ancillary data
  • Serum analysis
  • CSF analysis
  • Radiologic data
  • Neurophysiologic data (EEG, EMG, etc.)
  • Other data
• Assessment
  • Localization of the lesion(s) if focal or multifocal process suspected
  • Etiology-based differential diagnosis
  • Most likely diagnosis with the current data
• Plan
  • Diagnostic plan
  • Therapeutic plan
• Academic discussion
  • Should include a review of the literature about a feature of the diagnosis or presentation. The literature review should tie-in the significance to the case presented. Limit the discussion to 1000 words and 4 references.

Students must request verbal feedback at the end of weeks two and four and note this on their clerkship card. In addition, at the end of each rotation, students should hand evaluation forms to the faculty members who supervised them. Written evaluations from locums, fellows or specialists cannot be accepted. In addition, we appreciate student feedback about the course and students have the opportunity to provide written feedback on the day of the written examination.

On the last Thursday of the clerkship (week four), the final examination is administered. The examination administered is the National Board of Medical Examiners Clinical Neurology Shelf Examination. This is a standardized examination, and is similar in format to the USMLE Step 2 examination. The exam consists of multiple-choice questions, and is timed for two hours, 10 minutes. By administering this exam, students can compare their knowledge to others nationwide, and the clerkship leadership can assure that the materials taught and methods of teaching in the clerkship are adequate to prepare students for a national exam. If a student misses the exam due to an emergency or conflict, it can only be made up at the end of the subsequent clerkship block.

On the last Thursday of the clerkship, after the written examination, each student will meet with the clerkship director for a brief oral examination. The examination will consist of discussion of three clinical vignettes. The student will be asked to read each vignette, and then discuss the diagnosis and therapy with the examiner. Five minutes will be allotted to each vignette, for a total exam time of 15 minutes.

No one book is perfect for the purposes of this course. However, students must come up with a structured reading plan. “Reading around cases” is encouraged but will not suffice in learning the required materials. The successful student will read one of the suggested readings cover to cover. They have been selected for their length, so that they can be read in four weeks. The following is a list of recommended reading. Students should select one and read it through.

• Clinical Neurology by Aminoff. Part of the Lange Series, this book is thorough and is readable in four weeks. Probably the best book to use for the clerkship. Students who read this book tend to perform better on the examination.
• Introduction to Clinical Neurology by Gelb is a wonderful book that provides a great framework for clinical neurology. It is an easy read and uses clinical cases. Not as thorough as the Aminoff book, but certainly adequate. (Available in the Library at WCMC-Q.)
• Harrison’s or Cecil’s textbooks of internal medicine all contain thorough, readable neurology sections. They may be “dense”, but many students already own one of these books.
• In addition, for reference only, students could use Adams and Victor Principles of Neurology by Ropper and Brown, Merritts Neurology by Rowland, or Neurology in Clinical Practice by Daroff et al.

Like other clinical clerkships, neurology is graded on the Cornell system of:

• Honors
• High Pass
• Pass
• Fail

As mentioned above, poor attendance is the easiest ticket to a failing grade. Grades are based on performance in multiple domains and are weighted as follows:

• Clinical performance 35%
• Written examination 35%
• Write-ups 15%
• Oral examination 15%

Grading in this clerkship is transparent. A blank student assessment form can be found after this section. A failing grade on the written examination does not ensure that the student will fail the clerkship. However, if the student performs below the 20th percentile nationally, a failing grade for the clerkship will be automatically given, and the test will have to be retaken. There is no set number of students that will receive a certain grade. Each student is assessed on his/her own work and graded accordingly. Grades are usually available 4 weeks after the clerkship is completed. Students have the right to discuss their grading decision with the clerkship director if clarification is requested.

If a student misses the written examination for an excused reason, the test can only be made up on another date when it is being administered at its usual time, the last Thursday of a clerkship. Make-up oral examinations should be scheduled directly with the clerkship director.