AAN.com Talks to Fraser Moore About the Essential Neurologic Examination

August 14, 2009

Fraser G.A. Moore, MD, FRCPC, and Colin H. Chalk, MD, recently studied the problem of the essential neurologic examination and published their findings in Neurology® (2009; 72:2020-2023). AAN.com talked with Moore about what we ought to be teaching medical students about the neurologic examination. He spoke with Daniel B. Hier, MD, MBA, FAAN, AAN.com Associate Editor for Education.

AAN.com: You point out in your article that graduating medical students were often uncomfortable performing the neurologic examination. What was your original hypothesis as to why they felt uncertain about their skill in doing the neurologic examination?

Moore: The neurologic examination contains many different elements, reflecting the complexity of the nervous system itself. Experienced neurologists are able to select those elements that are appropriate for any given patient that they see. Our hypothesis was that medical students were uncomfortable with the neurologic examination because they were overwhelmed by the number of different elements and were unable to decide what the important elements were.

AAN.com: For the purposes of this study, how did you define essential neurologic examination?

Moore: We identified 94 possible elements that could be included as part of a neurologic examination. Some of them we knew from our own experience were only rarely performed, and no one would include them as part of an "essential" neurologic examination. We selected 46 elements and asked neurologists how likely they would be to include each element if they were seeing a patient who was unlikely to have findings on the neurologic exam, and they were using the exam to confirm their impression that the patient was neurologically normal. We gave them four possible choices:

1=I rarely, if ever, include this.
2=I include sometimes, but less than 80 percent of the time.
3=I include this at least 80 percent of the time.
4=I will always or almost always include this.

We considered an element "essential" if it received an average score of three or greater, meaning that the neurologists surveyed would include it at least 80 percent of the time in the clinical situation above. It is important to realize that although we feel that this method did define the important or "essential" elements of the neurologic examination, this was not the purpose of our study

AAN.com: In the article you mention using the Delphi Method: How did that assist you in getting to consensus?

Moore: The Delphi Method has been used in a variety of different fields, including medicine, to help achieve consensus. In our study we asked a group of neurologists to rate elements of the neurologic examination as described above. We calculated mean scores for each element, then asked the neurologists to repeat the process while letting them see the mean scores from the first round (thereby letting them know what their colleagues, on average, would choose for each element). After repeating this a third time, the standard deviations for each element were stable and we considered that we had achieved consensus.

AAN.com: What were the key elements that McGill neurologists and Canadian neurologists agreed were essential?

Moore: This would probably be more easily displayed in a table—see below. The results fit well with what each of us would typically do in that specific clinical situation. Again, the results (and number of elements) would change if we chose a different clinical situation, or if we chose a mean score other than three as a cut-off.

AAN.com: Did the medical students have a good grasp as to what was an essential neurology exam?

Moore: The medical students differed from experienced neurologists in the importance that they gave to some individual elements. For example, the students gave fundoscopy a low rating while they gave facial sensation a high rating. The neurologists rated fundoscopy highly and facial sensation low. However, our hypothesis was that medical students would have difficulty deciding which elements were important and would therefore rate many more elements as essential than the neurologists did. This turned out to not be the case, as both groups rated 22 elements as being essential.

AAN.com: Like you, I was surprised to learn that medical students had a good grasp of what constitutes an essential neurology exam. Do you think their anxiety about the neurology examination might be related to uncertainty about how to enlarge or change an exam for specific neurologic symptoms? Or do you think they might be uncertain about how to interpret abnormal findings?

Moore: Both of these are possibilities. I think that many medical students view the neurologic exam as an inflexible set of required tasks, and do not realize that most neurologists adapt their exam to individual patients. They very likely also have difficulty interpreting whether subtle findings are normal or abnormal. For example, when is finger-to-nose testing really abnormal, or is mild tongue deviation important? Another possibility might be difficulty with the technique of performing certain parts of the exam, such as visual field testing or checking for tone.

AAN.com: Thanks for speaking to us about your study of the essential neurology examination.

Moore: You are welcome!

High-rated elements of the neurologic exam. All items shown had a mean score of 3 or greater. Those in bold had a mean score of 3.5 or greater. McGill students received the original version of the survey given to McGill neurologists, and therefore light touch was not included.

McGill Neurologists	Canadian Neurologists	McGill medical students
Visual fields	Visual fields	Visual fields
Fundoscopy	Fundoscopy
Pupillary light reflex	Pupillary light reflex	Pupillary light reflex
Pursuit EOM	Pursuit EOM	Pursuit EOM
		Facial sensation
Facial muscles	Facial muscles	Facial muscles
		Sternocleidomastoid
Tongue	Tongue	Tongue
Gait	Gait	Gait
Tandem Gait	Tandem Gait
Pronator Drift	Pronator Drift	Pronator Drift
RAM upper	RAM upper	RAM upper
Finger-nose	Finger-nose	Finger-nose
Tone arms	Tone arms	Tone arms
Tone legs	Tone legs	Tone legs
Power arms	Power arms	Power arms
Power legs	Power legs	Power legs
Biceps reflex	Biceps reflex	Biceps reflex
Brachioradialis reflex	Brachioradialis reflex	Brachioradialis reflex
Triceps reflex	Triceps reflex	Triceps reflex
Patellar reflex	Patellar reflex	Patellar reflex
Achilles reflex	Achilles reflex	Achilles reflex
Plantar	Plantar	Plantar
Light touch		N/A
	Vibration
	Pin prick
	Romberg	Romberg

Author Disclosures

Dr. Moore has nothing to disclose.

Dr. Hier serves as Education Editor for AAN.com and is Director of Physician Practice for the Neuroscience Center of the University of Illinois at Chicago. He has received compensation for work as an expert witness in medical legal cases. Within the last 24 months, he has received compensation as a physician editor for the Neurology edition of MDnetguide.