Year : 2017 | Volume
: 5 | Issue : 1 | Page : 1--8
Demystifying neurology education: Understanding the malady of 'neurophobia' among medical students and promoting 'neurophilia'
Bhaskara Pillai Shelley
Department of Neurology, Yenepoya Medical College, Yenepoya University, Mangalore, Karnataka, India
Bhaskara Pillai Shelley
Department of Neurology, Yenepoya Medical College, Yenepoya University, Mangalore - 575 018, Karnataka
|How to cite this article:|
Shelley BP. Demystifying neurology education: Understanding the malady of 'neurophobia' among medical students and promoting 'neurophilia'.Arch Med Health Sci 2017;5:1-8
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Shelley BP. Demystifying neurology education: Understanding the malady of 'neurophobia' among medical students and promoting 'neurophilia'. Arch Med Health Sci [serial online] 2017 [cited 2018 Apr 19 ];5:1-8
Available from: http://www.amhsjournal.org/text.asp?2017/5/1/1/208198
'Different from all other medical specialties, save perhaps psychiatry, the neurologist is heavily dependent on listening to and interpreting what the patient tells us… If you don't know what is happening by the time you get to the feet you are in real trouble'
–Jerome M Posner, 2013
Traditionally, the subject of neuroscience and clinical neurology has been one of the most difficult courses for medical students in undergraduate medical education. This educational phenomenon characterized by negative sentiments of anxiety, dislike, and disinterest is known as 'Neurophobia.' This term first coined by Ralph Józefowicz, a Professor of Neurology in the United States, describes 'a fear of the neural sciences and clinical neurology' which is said to affect 50% of medical students at one point during their training. The syndrome of Neurophobia is linked to medical student's daunting perceptions and beliefs associated with neurological education, in addition to their perceived difficulty to apply basic sciences knowledge to clinical scenarios. Indeed, neurology remains an area of the medical curriculum that students and residents alike continue to avoid. Thus, the medical students find neurology hard and challenging and do not feel comfortable performing the neurological examination on patients, a malady that has been observed by many studies to be a global pandemic. In my opinion, this indeed needs to be addressed as a major problem in medical education today since this malady is overwhelmingly due to the lack of vertical integration of basic neurosciences knowledge and clinical neurology into a cohesive whole that would sculpt the edifice of an 'effective neurologist clinician' in the making. I would stress that practicing neurology is an iterative process that demands a complex interaction between the accumulated basic sciences knowledge underlying neurology (neuroanatomy, neuropathology, neurogenetics, and neuropharmacology) and the skillful 'art and science' of the neurologic algorithmic approach as applicable to the various clinical situations coupled with the tenacity of clinical rationalism, clinical reasoning skills, and judgment.
To begin on a personal note by looking back into my formative undergraduate and postgraduate years in medical school training, I did not have the fascination towards basic neurosciences and clinical neurology as passionately as I had for cardiology. During my undergraduation, I still recollect my excitement and obsession on cardiac auscultation skill, art of stethoscope use that I endeared as emblematic of hands-on doctoring, listening to cardiac simulators, the thrill of reading and mastering electrocardiograms (ECGs), and the dynamism of cardiology. During postgraduation in Internal medicine, I did hone insights into clinical neurology skills, its history taking, neurologic symptom profile, symptom analysis and neurological examination, and diagnostic formulation, but I do admit that I did always have a 'subliminal fear' for a neurology long case. After my postgraduation in Internal Medicine, I did spend few fruitful and memorable years in the acquisition of experiential clinical knowledge as well as teaching medical students. By the twist of destiny, I soon began my residency training in Neurology. I did wonder what could have influenced my decision to select Neurology after having had spent some very exciting years in Internal medicine. I would attribute this to some of my early life experiences. Ever since I could remember, I always did have quixotic curiosities on the 'brain-mind' connection, the 'terra incognita' and the enigma of the 3 pound gelatinous 'supercomputer' and the extraordinary qualities of the mind that made Homo sapiens unique from other animals, the human intelligence, the human creative genius, and the rise of our civilization.
I still recollect one of my earliest memories of my fascination with the brain i.e. when my beloved late father in Brunei brought home a 'Newsweek” magazine of February 7,1983 which featured an enthralling article entitled “How the Brain Works“. To this day, I have still preserved this 8-page article. The mysteries of the brain was alluded to in this article through the works of neuroscientists. The conclusion of neuroscientists in demystifying the brain, I quote from the Newsweek magazine: “The extraordinary qualities of mind that make man human may be nothing more than an interaction of chemicals and electricity inside the labyrinthine folds of the brain“. Such understandings of the brain-mind connect ingrained in me did certainly pave way for 'neurophilosphical and neurotheological ruminations' much later on in my neurology career while I spent a sabbatical at the Institute of Neurology, Queen Square, London with my mentor Professor Michael Trimble, a clinician scientist blended into one as a behavioural neurologist, a neuropsychiatrist and a neuroanatomist.
My innate curiosity on 'brain-behaviour' puzzle was fuelled at a young age by certain emotional sentiments that involved the loss of my loved close relatives especially my 'silver-haired, affectionate' maternal grandfather who had suffered from neurological disorders. Since then what I hated most about life was death and pledged to be a doctor to prevent death. Though I was naive then, today as a doctor, I do realize that Medicine is an imperfect science (Medicine is a science of uncertainty and an art of probability - Sir William Osler). No matter how much science has advanced, we need to recognize limits of our knowledge, our necessary fallibility; our incompleteness of medical knowledge and as doctors we need to accept and confront the inevitable truth or tragedy of life i.e. mortality, dying and death, a biological actuality of our human life-cycle. Since that young age, I could relate to the traumatic, catastrophic, and 'dehumanizing' effects of the burden of neurological disabilities my loved ones had to endure and later the anguish and void when I learnt of the tragic loss of their lives. Perhaps these “unforgettable experiences” sowed the seeds of 'the feeling physician' in me. Even today, I would reiterate medical training should not only sculpt the mind, instead educate emotions (humanities) to empower physicians 'to think with your head and with your heart” that would curtail 'professional alexithymia'. Furthermore, after postgraduation, I did begin to conceptualize Neurology as the only specialty heavily reliant on clinical acumen. I was stimulated by the analytical and algorithmic approaches to neurological problems that narrowed down the differentials for the syndromic neurological semiology. With the many dramatic advances and breakthroughs in diagnostic, therapeutic neurology, and preventive neurology I considered Neurology fascinating, intellectually satisfying and the ultimate cerebral specialty for my career selection.
Although I did not suffer from the 'malady of Neurophobia' I was certainly dismayed at the redundant schema of 'inspection, palpation, percussion, and auscultation' for physical examination, the limited role of the stethoscope, and to learn the art and science of precise focused neurological examination using my 'neurological toolkit' with tools such as the Queen Square knee hammer, ophthalmoscope, measuring tape, pen torch, cotton wool and pins, a 128 and 512 Hz tuning fork, a 3 m Snellen chart, pin hole card, red/white pins, smell bottles, taste bottles, empty blood tube (for cold/hot tap water), two-point discriminator, and optokinetic flag. Having had mastered the ECG in Internal medicine, came the 'rude shock' of learning 'the 16 channel paper electroencephalography (EEG)' that was 50–60 pages long and 1 cm thick, although my ECG skills still stood in my favor in the clinical assessment of disorders involving the 'brain-heart' connection (Neurocardiology), and ECGs in syncope. As luck could have it, I did skillfully re-learn the adequate techniques for the use of my stethoscope to auscultate for bruits in cerebrovascular disorders. I did learn that the presence of an ipsilateral carotid bruit certainly did increase the clinical justification and urgency for requesting a Doppler ultrasound in a symptomatic patient with suspected TIA or Stroke. I also did learn the need to examine for spinal bruits in 'potentially treatable' vascular myelopathies (dural, intradural AVMs/AV fistulas), for localized supraclavicular bruits in the detection of subclavian or vertebral origin artery stenosis, and even did resort to learn to use the 'edge of the stethoscope' to elicit a tendon jerk when the percussion hammer was not readily available. In our 'high tech' era of expensive neurovascular and neurosonological imaging techniques, I as an ardent disciple of targeted bedside neurological examination, would not hesitate to state that the simple auscultation of the neck for carotid bruits (in symptomatic strokes, TIA) not to be considered redundant. Even today, I would pledge for mastering the 'art' of good bedside Clinical Medicine and practices. It is quintessential never to allow the 'art of clinical skills' to wither away which will only result in the 'atrophy of clinical skills'.
'No doctor can be omniscient. There will always be patients with rare conditions that the doctor is not familiar with. Keeping an open mind about potential diagnoses and listening carefully to the patient's story is important'
- Claude Bernard
As I saw many neurological cases during my neurology residency, I did learn which symptoms and signs 'should be present' and also importantly which 'should not be present' in a syndromic diagnosis which ingrained in me the 'pattern recognition' skills. I did realize the wisdom of clinical rationalism that while constructing the broad differential diagnosis, clinical neurology sometimes is not like mathematics, and the need to learn to use the Bayesian paradigm of probabilities and inculcate the principles of Occam's razor and Hickam's Dictum. It became exciting for me to master the skills of neurological interview, an active process of history taking, simultaneous processing of information, formulating a hypothesis or multiple hypothesis, rejecting some as further historical data appear and finally being able to plan for a focused and targeted neurological examination to verify and confirm the data obtained from history taking. This clinical rationalism sets the stage to answer three fundamental questions: Where is the lesion-Neuro localization, What is the nature of the lesion [Pathology], and Why the lesion [Etiology]? I certainly did develop clinical and cognitive skills in logical deductive analysis, inductive reasoning, and critical thinking for a systematic approach to localization, in addition to learning the non-analytical pattern recognition skills.
From my 'subliminal fear' for clinical neurology during my Internal medicine residency, my rigorous training, clinical experience, and the several mentors that have trained me along the way during my neurology residency did rekindle my 'latent Neurophilia'. I did have a successful emotional journey to an effective educational learning experience in neurology, with my mentors having a positive motivational influence on my learning thereby reducing the stress in neurology-related learning tasks. Since my mentors were able to reflect and pass on their 'Neurophilia' to me, I would state that my 'repressed' fascination for neural sciences and clinical neurology became more evident to me. Thus, these years did really transform me into a disciple of 'Neurophilia' competent to formulate a syndromic, topographic, and etiological diagnosis. In the later years while I worked as a teacher in Neurology, it has been my teaching philosophy to reflect on my students that the subtleties and complexities of the clinical examination and history, and the diagnostic formulation in clinical neurology is akin to the deductive abilities of the detective mystery fiction of Sherlock Holmes, and that a neurology case sheet is indeed a piece of 'detective writing.'
WATSON: You speak of danger. You have evidently seen more in these rooms than was visible to me.
HOLMES: No, but I fancy that I may have deducted a little more. I imagine that you saw all that I did.
–A. Conan Doyle
The skills of observation, inquiry, inductive, and abductive reasoning used to solve a crime puzzle is very much anologous to the methods that are needed for a sound and rational clinical judgment in neurological diagnostic formulation. Therefore, I would not hesitate to portray the fact that Sherlock Holmes with his immaculate 'science of deduction' was indeed a neurologist at heart. A skilled neurologist is a clinician sleuth who avidly hunts by learning using their eyes, ears, hands, and minds for possible clues as he greets the patient, observes and analyses the patient's social graces, dressing, comportment, mood, behavior, and how the patient walks into his examining room, thus the discipline of Neurology earning the reputation as 'queen of clinical disciplines.' As an endeavor for narrative medicine and interests in the 'arts', undergraduate medical students should read 'The Adventures of Sherlock Holmes' to understand Holmesian reasoning and other crime novels by authors such as Edgar Allan Poe (detective Auguste Dupin), Agatha Christie (Hercule Poirot), Raymond Chandler (Philip Marlowe), Dashiell Hammett (Sam Spade), and Georges Simenon (Jules Maigret). In my opinion, these stories underline the observational skills, great attention to details, unbiased systematic scrutiny of data, rigorous process of reasoning, problem-solving in the relentless and compulsive pursuit of diagnostic prowess, truly reminiscent of the 'modus operandi' of an effective neurologist clinician.
During these decades of learning in medical schools and later as a teacher in Neurology, it was not uncommon that I saw medical students with the negative attitudes and emotions (insecurity, anxiety, and fear) towards learning the complexities of neurology and face the challenges of logico-deductive analysis for the construction of syndromic formulation. This cohort of students firmly held a reputation of Neurology being particularly difficult among the various medical specialties and that basic neuroscience and clinical neurology was ranked at the top of the list for difficulty in learning and complexity. How can we understand the genesis of Neurophobia? This negative attitude was attributed to (i) Neurology being ranked as far more difficult than any other discipline in a theoretical context; (ii) having less comfort and least confidence to handle neurology 'at the bedside', and (iii) Neurology to be the discipline students and junior doctors felt least knowledgeable about with the need to know basic neurosciences (neuroanatomy, neurophysiology, neuropharmacology, neuropathology, and neurogenetics). Being lost in the wilderness of the “jungle of Neurophobia“, their knowledge of disorders of the nervous system was said to be poorest, these students performed the neurological examination inadequately, were intimidated by Neurology's reputation as a tough “head to toe” complex subject, and had less confidence in practical clinical situations in Neurology than in other system disorders. Furthermore, practicing junior doctors indiscriminately did resort to referring patients even with simple, common neurological conditions to neurologists to avoid having to deal with them.
Is clinical neurology really so difficult? I would reiterate that the genesis of Neurophobia stems from a major drawback of neurology education in medical schools today. There is a lack of integration of basic science and clinical information into a cohesive whole, as these subjects are taught in a “piecemeal” fragmented manner in a vacuum. As a result, the medical student frequently is not able to develop clinical reasoning skills (analytical and non-analytical skills), lacking competence in a focused neurological examination, and inability to apply their knowledge of basic sciences to clinical situations. This hinders the process of logico-deductive diagnostic formulation that leads to negative emotional experiences such as anxiety, dislike, and eventual disinterest in the neurology subject. Due to the nonintegrated, nonblended, and fragmented working knowledge in basic neurosciences and clinical neurology, the students perceive that the neural sciences and clinical neurology as overly complex, and they develop a reluctance to approach neurological cases thus generating the syndrome of 'Neurophobia.'
Many studies have examined Neurophobia in the United States (Schon, 2002; Zinchuk et al., 2010; Ramos et al., 2016), Canada, Asia, India (Gupta et al., 2013) Sri Lanka (Matthias 2013); China (Lukas, 2014); Singapore (Kam et al., 2013), Middle East (Saudi Arabia, Abulaban et al., 2015), United Kingdom (Pakpoor et al. 2014), Ireland (Flanagan, 2007), Europe, Australia, New Zealand, and Caribbean (Youssef, 2009). Neurophobia, an endemic chronic disease among medical students and junior doctors, is certainly a well-documented phenomenon worldwide. All these studies did confirm that Neurology was ranked as the most difficult subject among all other medical subspecialties. These studies provided the potential evidence of the prevalence of Neurophobia which may be as high as 50% among medical students, and indeed a real educational phenomenon worldwide. The contributors to the genesis of Neurophobia in many of these studies were postulated to be related to insufficient or poor teaching by a non-neurologist, complexity of neuroanatomy and basic neuroscience, complexity of clinical examination, and limited inadequate exposure to neurology patients during their training curriculum. The 'symptoms' of Neurophobia does include intimidation, 'neuroanxiety,' a lack of confidence clerking neurology patients, avoidance of examination of nervous system, and a cynical and nihilistic attitude towards neurological diseases. Another troubling aspect of the 'Neurophobia' that develops during undergraduation is the fact that it may persist into their graduate training and professional careers. A major 'sign' of Neurophobia is the inability to localize focal lesions in the nervous system. The complexities involved in learning neuroanatomy is rooted to difficulties with the spatial reasoning skills needed to make mental conversions between two-dimensional (2D) images of the brain and the 3D reality of neural structures.
'Let someone say of a doctor that he really knows his
physiology or anatomy…. These are not the real compliments;
but if you say he is an observer, a man who knows how to see,
this is perhaps the greatest compliment one can make'
–C. G. Goetz and J. M. Charcot
Neurology is all about taking a great history and a focused meticulous examination. An effective neurologist clinician should be diligent, be curious about patients' stories, an excellent communicator, an intent listener, a sound decision maker with an empathetic and compassionate to provide the best neurological care. They should be skilled in clinical reasoning, have detailed knowledge, be proficient in organized, systematic and analytical thinking for complex problem solving using sequential hypothesis generation and thinking in terms of probabilities, not absolutes and knowing what is important and what is not.
The knowledge of the central and peripheral nervous system, its anatomy, physiology, and pathology, needs to be blended and interwoven to a targeted focused neurological examination. It is important to realize that this neurological examination is the most meticulous and time-intensive exercise when compared to any other medical examination for the complex decision-making and diagnostic formulation. Since the neurologic diagnosis is based on thorough history and focused physical examination, there are no diagnostic tests for differentiating dementias; differentiating seizures, syncope, and convulsive syncope; benign positional paroxysmal vertigo vis-à-vis the more sinister pseudo-benign paroxysmal positional vertigo of cerebellar or brainstem origin; peripheral radial nerve palsy and the chameleon of cortical hand knob area vascular infarction; differentiation of an migrainous phenomena, transient ischemic attack, and an epileptic disorder and in differentiating Parkinson disease (PD) from atypical PD syndromes.
'If you have thirty minutes to see a patient, spend twenty-eight
Minutes on the history, two minutes on the examination, and
No time on the skull X-ray or EEG'
–Adolph Sahs, 1987
Well known Lord Platt from University College of London had said in 1949, 'if you listen to the patient long enough, he/she would tell you what is wrong with him/her.' I reiterate this holy grail of bedside medicine, i.e. 'First, Clinical Bedside Examination then, and only then, armamentarium of Investigations' by alluding to the results of a prospective, double-blind, randomized, hi-tech based study of the role of history taking, physical examination, and investigations in medical diagnosis. Studies done 20 to 30 years ago performed in the general medical outpatient setting did attempt to quantify the relative contributions of the history, physical examination, and laboratory investigation in making a medical diagnoses. Two such studies noted that the history alone provided the diagnosis in 76%–82% of cases., One such study published in 1975 by the students of Lord Platt in British Medical Journal  concluded that 80% of the accurate diagnosis was achieved even before the physical examination, at the end of listening to the patient and reading the referral letter which could be refined 4% more by physical examinations and only 8% by all the investigations. Even to this date, this study does emphasize the centrality of history-taking and the examination of patients which is the quintessential cornerstone in the neurological interview and bedside clinical neurological diagnostic formulation. More recently, in India in the year 2000, Roshan and Rao attempted to quantify the relative contributions of history-taking, physical examination, and laboratory investigations in making medical diagnoses. History-taking was responsible for the diagnoses of 78.6% of all patients. Physical examination was responsible for another 8.2% and laboratory investigation a further 13.2% of all diagnoses. All these data certainly reiterates that the most important investigations we have ever devised for obtaining clinical diagnoses are history-taking and physical examination!
The lack of completeness of neurological examination by medical staff was reflected in a recent 'The TOS UK Study' (2012) where 33% and 48% of inpatients said that they had not been examined with tendon hammer and an ophthalmoscope respectively before they were referred to the neurologists. In another recent study, it was found that examination in addition to history-taking did increase the diagnostic yield, but examination alone only led to a diagnosis in 1% of patients. Therefore, the art of history-taking and examination are the two sides of the same coin of 'bedside medicine' and that the two work synergistically to facilitate clinical bedside diagnosis. Teaching medical students how to perform a neurological examination is a challenge. In Neurology, in view of the anatomical vastness of terrain where the lesion could be, a meticulous history-taking coupled with analysis of the symptoms cluster needs to be combined to a clinical examination that is tailored to the individual clinical problem. I term this as the targeted, restricted, focused 'hypothesis driven approach' bedside clinical neurological examination rather than the traditional 'screening approach' to neurological examination. Students need to adopt a hypothesis-based level of neurological (focused) examination, where the clinical hypotheses that is derived from the interview of a patient will steer the examination.
As compared to other medical specialties, clinical neurology does demand a genuine dedication, discipline and thoroughness that incorporate a systematic, hierarchical, algorithmic approach, and pattern recognition skills. Given the complexity of neurology as a vast subject and rigor of bedside clinical neurology, there is a paradox today in medical students and junior doctors to circumvent the time intensive, and logico deductive clinical neurological reasoning. Instead placing an undue reliance on the complex and modern neurological investigations as a substitute to bedside neurology skills thus promoting Neurophobia, lack of clinical-skill acquisition, and hyposkillia. An incomplete neurological interview and slipshod assessment often lead to unnecessary tests or scans to be used as surrogates for diagnosis or excluding neurological disorders. One such clinical misadventure is the risk of overenthusiastic imaging resulting in “victims of modern imaging technology” (VOMIT) which further leads to unwarranted and ominous referrals based on the results of such unnecessary investigations.
Even in the 21st century, I underscore that the science and art of medicine should be based on a thoroughly constructed medical history, coupled with a meticulous focused physical examination, critical assessment and a good clinical reasoning power the so-called 'méthod anatamo-clinique' of Charcot. Apart from the clinical diagnostic formulation, this professional encounter of 'listening' ('listening to' and 'listening with' the patient) does re-humanize 'high-tech, no touch' Modern medicine to its Oslerian roots. In my passion for clinical bedside medicine especially bedside neurology, I would underscore that the significance of clinical methods should always be preached, practiced, and should never lose its priority. In a similar vein, despite the tremendous advances made in diagnostic neuroimaging, bedside clinical neurological skills (precise history taking, meticulous examination, bedside clinical localization, syndromic formulation, and differential diagnosis) still does remain the key to not only a safe patient care and rapid clinical diagnosis but also to ensure that appropriate timely investigations are requested.
'The proper study of mankind is man's brain; the ultimate
Purpose of the practice of medicine is to protect the brain'
–Fred Plum, 1988
Neurological disorders dehumanize in a way that heart disease and renal failure do not. The uniqueness of these disorders and their impact on people is part of what makes Neurology fascinating, challenging and rewarding from not only a diagnostic, therapeutic, preventive neurology perspective but also from a humanitarian perspective. This is because of the impact that “Neurology needs to be considered as a public health issue” since neurological afflictions does certainly have the potential for devastating outcomes on the mental capital and wellbeing. Neurological disorders such as dementias, traumatic brain injury and stroke are now the hidden epidemic of 'neurologic disability' in India. This reiterates the need to restructure Neurology education, clinical neurology training, and breakdown medical students' Neurophobia, promote Neurophilia, and enhance junior doctors' motivation in selecting neurosciences as their specialization to fill the workforce gap, tackle the unfavorable neurologist to population ratios, and the currently 'looming shortage of neurologists' in India.
Pondering on this humanitarian perspective, the World Health Organization estimates for 2030, the number of disability-adjusted life years secondary to neurologic disorders will be 7% of the total for all diseases, and 12% of deaths worldwide and 14% of total years lost due to disability will be attributed to neurologic disorders. This magnitude of the total burden of neurologic disorders would thus mandate a substantial need for neurologic care. This neurological burden would fall on non-neurologist general physicians since there is a shortage of neurology workforce in our country. Neurophobia has putatively caused medical students and practicing physicians not learning neurology and neurosciences sufficiently well which is also directly associated with higher likelihood of not specializing in the field of neurology and not selecting neurology as career options.
Selecting a career option in neurology, I would say, is one of the most important professional decisions one will have to make, and many students compile a list of advantages and disadvantages for each specialty they are considering to make that decision a bit easier. It seems vital to encourage potential neurologists from the very earliest stages of their careers in medical schools and continue through medical training with direct exposure to clinical neurology. Future career choices are still strongly influenced by both experience of a subject as a medical student, and the emotional and experiential learning imparted by 'role model' teachers and/or department during our formative clinical years.
In India, there are less than 1200 neurologists in our country with a ratio of one neurologist to 1,250,000 Indians. This is in stark contrast to that of 1 for 26,000 population in the USA and 1 for 53,000 in Canada. India is facing a public health crisis in providing neurology services, particularly at the district, taluk, and primary levels. It is obvious that the organization of neurology services in India has tremendous challenges and there is an urgent need to increase the neurology workforce. A study from India was undertaken to analyze and understand various factors, which students consider for and against choosing Neurology as their career specialty after medicine residency. Out of the 243 postgraduate students enrolled in this study, Neurology was found to be the first career option in only 19% of students. It is, therefore, crucial that Neurology education at undergraduate level should shift from neurophobic tendencies to Neurophilia to enhance the number of doctors choosing neurology as their career option. Looking from another perspective, it is disappointing to note that there are only 90 institutes in India providing training to 200 neurology residents annually. Thus, there is a high priority to enhance the number of teaching institutions to provide Neurology training (DM and DNB in Neurology), Neurology fellowships and yet maintain high standards of teaching and training in Neurology training curricula to meet the enormous workforce gap in India.
Having understood the complexities and reality of the global pandemic of Neurophobia, what should be the futuristic cure for Neurophobia? What are the evidence-based strategies to effectively integrate the teaching of basic neuroscience and clinical neurology which would facilitate a culture of 'Neurophilia ?' Can Neurophobia be tackled? Medical students should be exposed to clinical neurological problem oriented acquisition of core knowledge and skills at neurological examination sufficiently early in their clinical training. Learning neurological examination is not a single step process but one that continually needs to be mentored, improved on, and refined over their training. The training should be based on the Miller's pyramid for assessing clinical competence, i.e., 'knows, knows how, shows how, and does'. During their training, the medical student's proficiency will depend on gaining competence to progress through the pyramid. As they successfully progress from the 'knows' (knowledge of basic neurosciences) to 'know how' (integrating basic knowledge to clinical problems) to 'shows how' (neurological examination observed by the neurology tutor in a patient with a problem) and 'does' (independently having the proficiency to examine), the novice student would have tackled their neurophobic attitudes to gain a tendency for 'Neurophilia.' As educators, we should employ evidence-based integrative and instructional strategies to facilitate the shift and acquisition of competence upward through the Miller's pyramid as the way forward to prevent 'Neurophobia.' Since, one of the main reasons why Neurology was considered difficult was the lack of knowledge in basic neurosciences and neuroanatomy, this deficiency could be remedied through enhanced vertical integration of preclinical basic neurosciences of neuroanatomy and physiology and clinical neurology teaching sessions (through a problem-based learning approach) with emphasis on increased bedside tutorials and patient exposure. Teaching of neurological principles with appropriate didactic methodology and feedback and sufficient integrated practical training could certainly improve effective learning experience in Neurology. It is also important to realize the need to remodel neurology education, to reevaluate and reconstruct undergraduate curriculum in order to enhance student interest and to promote organized involvement in neurology education. In this respect, effective educational frameworks include the early timing of preclinical neurology education, the role of motivated clinician-educators (mentorship) with Neurophilia, and increasing the length and focus of Neurology rotations sufficiently early during the undergraduate training. All these strategies will go a long way not only to demystify neurology education and prevent Neurophobia but will also be instrumental in increasing the number of medical students pursuing Neurology as career options.
The plausible reasons for the neurophobic tendency were centered on the need to know basic neurosciences, and neuroanatomy in particular; the amount, type, and quality of the teaching given; and the difficulty in carrying out a neurological examination. This would translate to the need to integrate basic neuroscience teaching with clinical neurology, the need for better instructional and evidence-based teaching strategies, the need to make neurological teaching simplistic, basic, and straightforward with clinically relevant parts of anatomy, physiology, pharmacology, and pathology, set in a continuous clinical context. Since the majority of patients in India and UK are seen by the non-neurologists and general medical physicians, there needs to be a major emphasis on a simple, more user-friendly and accessible evidenced-based Neurology education right from the start at medical school, allowing medical trainees to build up their knowledge and clinical confidence as they proceed thus attenuating their tendencies for Neurophobia. Perhaps this will set the way forward for the next generation medical students, junior doctors and the non-neurologists towards Neurophilia.
We need to train our students and junior doctors to use cognitive faculties of heuristics (a decision strategy, however, acknowledging with a grain of salt, the several heuristic pitfalls), and a Bayesian approach to probability assessment to help them through complex clinical information and formulate a diagnosis efficiently. A neurological examination is similar to solving a 3D jigsaw puzzle, where a diagnosis is reached by the clinical problem solving that is based on neuroanatomical knowledge, and a proficient clinical thinking ability to convert abstract concepts into concrete reasoning. Teaching our students how to recognize clinical patterns or syndromes while remaining thorough and open to the unexpected remains a challenge. Perhaps the combination of 'hypothesis-driven' examination style with that of the traditional 'screening' neurologic examination does seem to be more sensible.
'Education is not the filling of a vessel but the lighting of a flame'
I would underscore that Neuroscience educators would need to reinvent 21st century educational strategies by understanding a 'Brain-Based Approach' to learning and teaching in medical schools. This will undoubtedly create a conducive and exciting environment for the 21st century learners in Neurology. Brain based learning strategies and other innovative multi-dimensional approaches will remodel Neurology education, orchestrate and optimize the medical students' learning experiences. To stamp out 'Neurophobia', I would unhesitatingly state that time has come for Neuroscience educators to make a paradigm shift from the traditional discipline-based, Flexnerian curriculum to an 'integrated curriculum architecture' that will permit enhanced integration between basic neurosciences and clinical and bedside neurology, thus assuring a student-centered 'competency based education' in Neurosciences.
Instructional strategies employed for teaching neurosciences in undergraduate curricula traditionally include a combination of lectures, demonstrations, practical classes, problem-based learning, and clinicopathological conferences. Evidence-based solutions for the 21st century Neurology/Neurosciences education must integrate 'technology enhanced learning' with novel 'brain-based' teaching learning strategies which will radically empower medical students' for an active, more engaged and self directed learning. It is my view that educational research landscape should be realigned away from the traditional classroom pedagogy, and it is highly imperative to “re-think and re-design pedagogy for the 21st century digital age classroom“. The technological rise of the 21st century should provide a platform in medical universities to facilitate integration of pedagogy and online (web based) and evidence based 'information and communication technology' (ICT) technology. By integrating this novel approach of 'blended learning and flipped' teaching-learning strategy into the 21st century classrooms would certainly re-invent and re-design curriculum for a student centered, and novel teaching learning strategy. This blended approach would certainly help students organize, re-engage and manage their learning approaches for deeper understanding through self-directed learning (SDL), problem-based learning (PBL) and blended-PBL in Neurology. Other effective teaching methods also include team-based learning (TBL), Small group teaching, and case-based teaching modalities during students' rotations in Neurology in the undergraduate medical curriculum. The face-to-face teaching vs. technology-based teaching would reinvigorate and enhance medical students' learning experiences to develop their neurological observational and analytical skills using a blend of traditional classroom activities and computer-based materials (such as Web Course Tools, e-learning resources combined with a wide range of video clips of patients with neurological disorders on CD-ROM). Thus, it is imperative to formulate an evidence-based approach to enhance the quality of Neurology education and to improve the understanding of neurological semiology using innovative strategies. Such multi-dimensional innovative modalities include simulation-based medical education programs (SBME); technology-enhanced simulation training; 3D neuroanatomy teaching computer programs (simulation-based Anatomage table), web-based virtual learning environment (VLE), web-based blended learning (WBL), online neurology e-learning, Moodle e-learning platform and video tutorials. SBME is certainly effective for the integration of both clinical neurology and basic sciences such as neuroanatomy. I am sure that these novel initiatives, centered in adult and active learning theories, that go beyond the conventional didactic neuroscience teaching strategies, incorporation of student-centered active learning methods and technology enhanced learning will unquestionably change the learning landscape for Neurology education and to ultimately alleviate Neurophobia in the currently affected. It will also prevent the next generation of medical students and young doctors developing a fear for Neurology and the neurosciences thereby encouraging specialization in Neurology as career options. Medical students should be encouraged to read 'neuro-novels' (books by the British Neurologist Oliver Sacks), and be trained in Narrative medicine, and Cinemeducation (Neurocinema; The Diving Bell and the Butterfly on Locked in Syndrome; Awakenings on Encephalitis lethargica; Born on the fourth of July on Spinal cord injury) in Neurology to revitalize the centrality of patient's stories in the therapeutic and healing clinical encounter. This would undoubtedly promote Neurophilia among the medical students and be instrumental in developing empathy, professionalism, and communication skills resurrecting the 'humane touch' not only with patients, each other, and ourselves.
In this editorial, as a committed neurophile, I would coerce novice medical students and young doctors to develop a fascination and love for Neurology. Medical schools and educators need to re-structure Neurology education to enable students and junior doctors to make that leap forward, rekindle interest and gain that expertise and knowledge that could swing the pendulum from 'Neurophobia' to 'Neurophilia' which in my opinion is a precondition to become a neurologist. We need to ensure that medical students get sufficient time to learn neurological skills during their undergraduate training, implement educational interventions, and to adopt more evidence-based student-centered instructional strategies to help the students in bridging the gap in their cognitive knowledge to stamping out 'Neurophobia' and to kindle 'Neurophilia.'
“The task of the modern educator is not to cut down jungles, but to irrigate deserts.”
–C. S. Lewis
|1||Jozefowicz RF. Neurophobia: The fear of neurology among medical students. Arch Neurol 1994;51:328-9.|
|2||Krishnamoorthy ES. Michael Trimble: The quintessential clinician scientist. Epilepsy Behav 2005;6:469-72.|
|3||Holmes S. Neurologist? Cherington M. Neurology 1987;37:824-5.|
|4||Nicholl DJ, Appleton JP. Clinical neurology: Why this still matters in the 21st century. J Neurol Neurosurg Psychiatry 2015;86:229-33.|
|5||Peterson MC, Holbrook JH, Von Hales D, Smith NL, Staker LV. Contributions of the history, physical examination, and laboratory investigation in making medical diagnoses. West J Med 1992;156:163-5.|
|6||Hampton JR, Harrison MJ, Mitchell JR, Prichard JS, Seymour C. Relative contributions of history-taking, physical examination, and laboratory investigation to diagnosis and management of medical outpatients. Br Med J 1975;2:486-9.|
|7||Roshan M, Rao AP. A study on relative contributions of the history, physical examination and investigations in making medical diagnosis. J Assoc Physicians India 2000;48:771-5.|
|8||Nicholl DJ, Yap CP, Cahill V, Appleton J, Willetts E, Sturman S. The TOS study: Can we use our patients to help improve clinical assessment? J R Coll Physicians Edinb 2012;42:306-10.|
|9||Paley L, Zornitzki T, Cohen J, Friedman J, Kozak N, Schattner A. Utility of clinical examination in the diagnosis of emergency department patients admitted to the department of medicine of an academic hospital. Arch Intern Med 2011;171:1394-6.|
|10||Hayward R. VOMIT (victims of modern imaging technology) – An acronym for ourtimes. Br Med J 2001;326:1273.|
|11||Gourie-Devi M. Organization of neurology services in India: Unmet needs and the way forward. Neurol India 2008;56:4-12.|
|12||Gupta NB, Khadilkar SV, Bangar SS, Patil TR, Chaudhari CR. Neurology as career option among postgraduate medical students. Ann Indian Acad Neurol 2013;16:478-82.|
|13||Kamel H, Dhaliwal G, Navi BB, Pease AR, Shah M, Dhand A, et al. A randomized trial of hypothesis-driven vs. screening neurologic examination. Neurology 2011;77:1395-400.|
|14||Davies A, Ramsay J, Lindfield H, Couperthwaite J. A blended approach to learning: Added value and lessons learnt from students' use of computer-based materials for neurological analysis. British Journal of Educational Technology 2005;36:839-49.|
|15||Abushouk AI, Duc NM. Curing Neurophobia in medical schools: Evidence-based strategies. Med Educ Online 2016;21:32476.|