Neurology

Clerkship Director: Dr. Valencia Sanchez

Clerkship Length: 3 weeks

The Basics 

Neurology consists of a total of 3 weeks, where you spend either one week in the outpatient clinic and two weeks in the inpatient service OR two weeks outpatient and one week inpatient. If there are only a couple of students, they try to put you on two weeks of inpatient and one week of outpatient. Neurology doesn’t have a lot of extra busy work but keep in mind it is only three weeks and the shelf exam tends to be on the harder side so please prepare accordingly. Refer to Brightspace for full details of content and requirements. 

Assessments

1. Clinical Performance 65%

a. Based on your MedHub evaluations

2. Shelf Exam 25%

3. H&P Write-Ups 10%

a. Students are required to submit 2 H&P Write-ups from patients they have personally interviewed and examined

Honors: ≥ 85% overall score

High pass: 75-84% overall score

Pass: < 75% overall score

Clerkship Schedule Overview 

Below is what a typical student schedule might look like. 

On the first day you have an orientation with the clerkship director so make sure you are on time and aware of where it is located (it is usually at Scottsdale).  During the orientation they will go over the neuro physical exam (so brush up on it) and how to do a lumbar puncture.  In the outpatient clinic, you can expect to work with a different sub-specialty faculty each day. Clinic schedule is rather predictable and you will probably have patients from 8am to 5pm (may vary). Make sure you email them ahead of time and they will tell you which patients they expect you to chart, prepare for, and examine in the clinic. Most attendings will put “medical student will see” on the note for which patients they want you to see. On inpatient, sign out is at 7:00 am (brightspace says 6:30 am but it is really 7am) and rounds are usually at 8:30ish except on Wednesdays when they are at 8:00am. You can ask the residents on your first day to clarify when to report. The neuro chief will decide which week you will be on general neuro service and which week you’ll be on stroke service. While on inpatient for two weeks, you are expected to work on one Saturday. There are no night shifts during this rotation. 

Recipes for Success

• Borrow neuro tools from Dan before the clerkship begins or the Monday of your orientation!

• Clinical Performance Evaluation

  • Make sure you email preceptors in advance to ask about when to meet, where to meet, and any preparation they expect you to do before you start working with them. 

  • For clinic, make sure you preview patients in Epic before you see them. Have a good understanding of why the patient is being seen, any relevant past medical history, and relevant medications and review any critical imaging of the brain.

    • In Epic these are the key tabs you can go through: 

      • Snapshot

      • Encounters (read the notes from the neuro department, especially original neuro referral for encounter))

      • Results Review (for brain imaging)

      • Document Viewer / Care Everywhere (for new patients that may have transferred clinical documents from prior Neurology outside of Mayo). Many clinic attendings will expect you to know the entire relevant medical history while presenting. The outside documents are time consuming and often scanned PDFs. Some found it helpful to prepare patients the night before, especially if there are many outside provider notes to put together an interpretable timeline of the patient’s medical history prior to the encounter.

• When writing notes in Epic, it’s a good idea to ask your faculty if they have a preferred template they use. Copy their template and use it instead of trying to figure out what to do or starting from scratch! Read one of their prior notes and try to follow that format and language.

• You may be in a different subspecialty clinic each day: seizures, stroke, headaches, dementia, etc. 

  • In Brightspace there is a video log of didactics covering these topics. The day before you go into a subspecialty clinic it is a good idea to watch the didactic relevant to that clinic. If you know you will be working with Dr. Carter to see Multiple Sclerosis patients tomorrow, make sure you watch the didactic the night before because it will prime you for what to expect and ask in the clinic.

  • It is not necessary to watch all didactics. Just watch those relevant to you before going to clinic. 

  • Before seeing your patient, you can ask the attending if there are specific questions they want you to ask the patient. Each attending likes to ask different things, so sometimes after your first interview you learn what they are looking for. Attendings may email you a template of their preferred note the day before or day of your patient encounters. These often have prompts for the questions they ask during specific encounters such as for dementia, headache etc. Not all attendings will have templates, so have a note template you are comfortable with available. 

  • Clinic patients can be extremely complicated. Some find it helpful to bring their laptops into the encounter to simultaneously write their rough draft of their note/ presentation. It can also be helpful to reference the patient’s epic chart while in the encounter to verify history, medications etc.

  • Some clinic specialties may have more in- depth expectations regarding diagnosis, treatment etc. If necessary, access Continuum review articles through the American Academy of Neurology. Read the summary bullet points in the margins for quick and dirty information relevant to each speciality. See the MS article link below for example: https://journals.lww.com/continuum/Fulltext/2022/08000/Epidemiology_and_Pathophysiology_of_Multiple.4.aspx 

• For inpatient, there are three services: stroke, general, or consult. 

• • You may be assigned to a different service each day to get good exposure to a broad variety of neurology. 

  • You will be working in a team of attendings, chief resident, residents, and neurology PAs. 

  • You can expect to pre-round in the morning by going to see patients on your own, then discussing all patients in the resident room together at table rounds, and then going as a team to visit patients on the entire patient list. 

  • Typically the mornings are busy but the afternoons tend to have more downtime. 

    • Some residents prepare chalk talks, others don’t. All of the residents were very receptive to answering questions and reviewing topics when appropriate. It was helpful to bring in confusing UWorld questions to initiate a teaching moment. 

  • You should have a good grasp of the neurology full exam because you will need to do this for majority of patients on this clerkship both inpatient and outpatient! You get to practice during orientation as well and don’t be afraid to bring in your list into patient rooms! 

  • Stroke: you will see patients on neurology team for stroke events and participate in stroke alerts called in the hospital 

    • Tip: print out NIHSS for each patient you follow 

  • Consult: you will see patients in the hospital consulted for neuro assessment

  • General: you will see any non-stroke patient in the hospital for a neurological reason including encephalopathy, seizure, etc. 

  • Neurology inpatient tends to be much more relaxed with rounding and patient presentations compared to internal medicine.

  • Ask your residents about EPIC templates and which one you should use when!

    • 1. 1. • Templates (inpatient)

              • Arrow Page: progress template

              • Target Page: admission template 

              • Last page: full neuro exam in order

• H&P Write-Up

  • Students are required to submit two H&P write-ups from patients they have personally interviewed and examined. 

  • One write-up is due by the end of week 2 of the clerkship, and the other is due by Sunday of the last week. 

  • In Brightspace you will find grading criteria and an example write-up from a student. Follow that example to do your write-ups successfully. 

  • The write up can basically be a copied version of a note you write. HOWEVER, there are two additional sections: high value care and evidence based medicine. There is an example on brightspace for reference. Basically you should do a little research on the treatment plan presented and defend choices for evidence based medicine. For high value care, you should touch on a variety of care costs and how they affect the treatment plan for example choosing brand vs generic medications, transportation, etc. 

• Shelf Exam

  • The shelf exam consists of 110 multiple choice questions

  • Tier 1 → You should aim to do all of the UWORLD for Neurology - that should be your main goal. If you have extra time you can redo your missed questions or redo the entire bank again. 

  • Tier 2 → Once you near the last few weeks of the rotation you should do at minimum two practice NBME exams, ideally all four if possible.

  • Tier 3 → If you have extra time you can watch the Online Med Ed or Osmosis videos for Neurology before or during the rotation.

  • Tier 4 → If you have even more time you can do the AMBOSS question bank for neurology clerkship

  • This clerkship is fast, so UWorld was the most efficient way to see the material in my opinion. UWorld questions were similar to practice shelf and shelf questions. Knowledge gaps can be supplemented with AMBOSS articles. If possible, go in with a plan that works for your study habits. There is little time to experiment with material before settling in, so stick to your plan. 

• You can also check out the Mayo Rochester Clerkship Guide.

Key Resources Quick Links

*most important resources are in red that you should do at minimum to pass

• UWORLD

  • You know where to find that!

  • Question bank is about 380 total questions

  • Do it all at least once!

• NBME Practice Exams

• Online MedEd or Osmosis

  • Check their respective websites for the videos

  • Here is the Online MedEd PDF booklet that you can scan quickly for review 

• NIHSS exam https://www.ninds.nih.gov/sites/default/files/documents/NIH_Stroke_Scale_508C_0.pdf

Sample Study Schedule

• Use this template and adjust to your own needs! 

Supplementary Clinical Content Pearls

• Templates (inpatient)

  • Arrow on top of page = progress template

  • Target on top of page = admission template 

  • Last page = full neuro exam in order

• You can also check out the Mayo Rochester Clerkship Guide 

End of Rotation Checklist

• H&P Write Up 1

• H&P Write Up 2 

• CEX Form - complete on your outpatient clinic week with a faculty member

Last updated in November 2024 by Isabella Reitz