2023 Neurology Clerkship Guide

Neurologists are physicians who specialize in the non-surgical management of a variety of central and peripheral nervous system disorders. The neurology clerkship gives medical students the chance to gain first-hand experience dealing with the most complicated and most essential organ in the human body, as well as a better understanding of what it means to be a neurologist.

“Everything we do, every thought we’ve ever had, is produced by the human brain.” – Neil deGrasse Tyson

This guide will cover the neurology clerkship, including when to place this rotation, how to make the most of your rotation, neurology clerkship resources, the Shelf exam, and the pros and cons of pursuing this specialty.

Intro to the Neurology Clerkship

Clinical clerkships, also referred to as clinical rotations, are opportunities for med students to practice medicine under the supervision of an established health practitioner or doctor. Clerkships provide students with first-hand knowledge of what a specific specialty is really like, which enables them to determine the field of medicine that most excites them and the one they want to pursue in their future medical career.

Most US medical schools require the following rotations:

• Family Medicine
• Internal Medicine
• Neurology
• OB-GYN
• Pediatrics
• Psychiatry
• Surgery

Additionally, some schools may also require other rotations, such as anesthesiology, emergency medicine, radiology, etc.

Neurologists manage everything from headaches and migraines to incurable and devastating diseases like Huntington’s disease and amyotrophic lateral sclerosis (ALS). Neurologists primarily deal with headaches, strokes, seizures, and dementia, but there are also a wide range of fellowship opportunities.

Neurology can be an emotionally challenging specialty, as a substantial portion of diseases in neurology, such as ALS, are chronic and progressive. But it’s a common misconception that neurologists mostly just diagnose conditions but can do little to actually treat them. Research in neurology is rapid, which means therapies are always improving.

For example, our understanding of strokes, the fifth leading cause of death and the first leading cause of disability in the United States, has improved drastically over the last few decades. Swift interventions, such as endovascular thrombectomy and tPA, are now known to be crucial in favorable outcomes. Care for epilepsy has also improved thanks to vagus nerve stimulation and new anti-seizure medications. And even in the case of ALS, clinical trials for novel therapies are showing a great deal of promise.

The neurology rotation is also fascinating as it’s the rotation where a diagnosis is made in an instant.

The beauty of neurology consists of the ability to determine one’s affliction just through history taking and clinical exams.

For example, when a patient arrives with left side palsy and right facial palsy that occurred in a matter of hours, you know it’s a stroke of the MCA. An ischemic stroke is quite possible if the patient is known with atherosclerosis (medical history).

The difference between the psychiatry and neurology rotation consists of the approach to the brain. Psychiatry deals with the mind—the processes that are spurred by neurons interacting. Neurology deals with the nuts and bolts of the brain, such as pathologies of the neural and glial cells or brain vessels.

When to Place the Neurology Rotation

Where you place the neurology rotation depends on your interest in pursuing it as a specialty. If you want to pursue neurology, do not place this rotation at the end; place it second or third out of the total of four quarters of the year.

This will ensure you have a basis of experience before going into the rotation you’re most interested in. By not placing it last, you ensure you are able to get adequate references for applying to residency programs, and you can make sure it’s actually the specialty you want to pursue by getting real-life experience in your rotation.

Making the Most of the Neurology Rotation

The rotation itself is similar to internal medicine, as it’s a mix of outpatient and inpatient. As during the internal medicine rotation, prepare for rounds that will last for a while. Also, make sure to ask plenty of questions in order to extract every piece of useful information.

Inpatient

Inpatient presents you with more severe cases, such as seizures, demyelinating neuropathies, or inflammatory neuropathy.

One of the most important skills in neurology is knowing how to rapidly diagnose the location of the lesion. Take a look at this quick tutorial on locations of neurologic injuries. Make sure you understand these concepts before your first round to impress the attending physicians.

While on the rounds, focus on SOAP:

Subjective: Take the patient’s medical history.

Objective: Perform the clinical exam and listen to the findings of the patient.

Assessment: Present your diagnosis and differential diagnosis (DDx).

Planning: How will you manage the patient?

For example, one of your first patients may be a patient who has recently suffered a seizure.

1. During the medical history, search for familial history of seizures, drugs that can cause seizures, or infections.
2. Objectively assess the patient neurologically for any deficits or signs of the seizure. After a temporal seizure due to HSV, the patient may become aggressive.
3. Allow the attendings on the rounds to understand how you ruled out other diagnoses (DDx).
4. Create a plan for continuing the care. Make a CT appointment and discuss with the resident which medication the patient should be put on (e.g.: valproate).

Outpatient

The outpatient clinic serves two purposes.

First, it helps you understand what the first steps are when admitting a patient. This process will be helpful during the Shelf exams. In this case, focus on the most common pathologies (“horses, not zebras” = “Alzheimer, not Creutzfeldt-Jakob disease”).

Secondly, the context will teach you continuity of care steps. For instance, when levodopa-carbidopa treatment for Parkinson’s starts manifesting on-off phenomena, patients will receive a COMT or MAO inhibitor.

Neurology Cheat Sheet

In order to impress the attendings, we gathered some of the most common conditions for you. This will prepare you for your first week during the rotation.

Stroke

Common presentations

• MCA (middle cerebral artery) stroke
  • Contralateral face, upper and lower limbs paresis
  • Aphasia on the dominant side (usually the left hemisphere)
  • Hemi-neglect if the stroke is on the non-dominant side
• ACA (anterior cerebral artery) stroke
  • Contralateral lower limb paresis and sensory loss
  • Urinary and fecal incontinence (loss of medial frontal micturition center)
• PCA stroke (posterior cerebral artery)
  • Contralateral hemisensory loss
  • Hemianopia (loss of vision in half of the visual field)
• Best initial diagnostic step
  • A non-contrast CT scan is recommended as a first step. This way you can differentiate between a hemorrhagic stroke (hyperintensity) or an ischemic stroke (hypointense area).
  • Although the MRI is more sensitive in the first 6 hours, it is not easily accessible.
• Management
  • For an ischemic stroke caused by an embolus consider fibrinolytic therapy within 3-4.5 hours of symptom onset. Contraindications to fibrinolytic therapy are:
    • Absolute contraindications
      • Signs of aortic dissection
      • Active bleeding/bleeding diathesis
      • History of ischemic stroke within the last three months
      • History of intracranial hemorrhage
      • Facial trauma within the preceding 3 months
    • Relative contraindications
      • Dementia
      • Pregnancy
      • Current warfarin therapy
      • Major surgery within the last three weeks
      • Prolonged CPR (>10 minutes)
      • History of chronic hypertension or uncontrolled hypertension at presentation (sBP> 185 mmHg or dBP > 110 mmHg)
      • Allergy to streptokinase/anistreplase
      • Internal bleeding/peptic ulcer in the last 2-4 weeks
• Management
  • If the patient has a superficial hemorrhagic stroke and elevated ICP, consider craniotomy with drainage.
  • Long term therapy (after the acute management) is similar to the therapy for coronary artery disease:
    • Aspirin +- clopidogrel
    • Statins
    • BP management (dBP < 80 mmHg)
    • Diet, exercise and weight management
    • If the patient is known with AFib, then opt for a warfarin treatment with an INR of 2-3.

Parkinson’s Disease

• Dementia occurs late in the disease.
• Pathology: patients have a depletion of dopaminergic neurons from substantia nigra.
• For the presentation of Parkinson’s disease (PD), remember TRAP.
  • Tremor (pill rolling): it is characterized by a low-frequency tremor of 4-6 Hz that ameliorates with voluntary action.
  • Rigidity: “cogwheel rigidity”
    • Test it with a Froment maneuver. It consists of flexing and extending the wrist while the patient moves his contralateral arm upwards and downwards.
  • Akinesia/bradykinesia: the patient moves slowly. The walking base is narrow, without arm swing.
  • Postural instability: the posture is similar to a question mark, the patient being anteriorly flexed.
• Patients may develop micrographia.
• Treatment of PD
  • Levodopa + carbidopa: levodopa increases the amount of dopamine centrally, while carbidopa inhibits levodopa use in the periphery.
  • Selegiline: MAOi, usually used in combination with levodopa and carbidopa (later in the disease, when the combination became inefficient)
  • Ropinirole, pramipexole: dopamine agonists used early in the disease
  • Anticholinergics (trihexyphenidyl or benztropine) — rarely used

Alzheimer Disease

• Most common cause of dementia.
• Pathology: deposition of neurofibrillary tangles, with depletion of acetylcholine.
• Presentation
  • Late findings include neurologic deficits, dyspraxia (difficulty with learned motor tasks) and urinary incontinence.
  • Early the single sign is the presence of memory loss.
• Diagnosis: clinical with an insidious onset of symptoms at an advanced age. Other conditions such as vascular dementia are excluded.
• Treatment includes
  • Memantine: in the moderate to severe cases, it prevents NMDA excitability toxicity.
  • Donepezil, rivastigmine, galantamine: cholinesterase inhibitors used in mild disease to increase acetylcholine which is depleted in patients with Alzheimer.

Vascular Dementia

• Second most common cause of dementia.
• Pathology: it is caused by multiple strokes or strokes and other cerebrovascular conditions (eg: autoimmune).
• Presentation
  • It develops in stages.
  • Signs of stroke (motor or sensory deficits)
  • Risk factors are present: HTN, DM, embolic causes (AFib), age, history of stroke.
• Diagnosis: MRI/CT showing signs of stroke (especially lacunar), focal neurologic deficits on the exam and the symptom onset is in stages.
• The treatment is similar to stroke management.

Neurology Clerkship Resources

The main study resource for the boards as well as for your Shelf exam should be UWorld Step 2 CK QBank. It fulfills two main points.

In the beginning, it helps you understand what to focus on during the rotation. For example, the vignettes on Alzheimer’s emphasize the CT findings. Thus, when dealing with a patient with Alzheimer’s, go look for their CT, understanding how the pathology is reflected on your patient’s CT.

Towards the end of the rotation, it is an amazing tool for active recall. It helps reinforce the basics learned and demonstrates what your weak points are.

A good companion is Blueprints Neurology. It is a short book that lays out the basics of each neurologic condition, which helps with thriving during the pimping of rounds.

As a complement, the Amboss QBank will challenge even the best neurologist. If you are passionate about pursuing this specialty, target their harder questions.

Lastly, the nervous system section from Step Up to Medicine is a concise review that’s very useful before the Shelf.

Some other students suggest the ninth edition of the Pretest Neurology book. For a passive approach useful during your downtime, such as lunch, Onlinemeded is highly recommended.

Neurology Shelf Exam

Your performance on the Shelf will be based on your combined activity in the hospital (outpatient/inpatient) as well as your study routine at home. The synergy between these two things can be approached in two ways.

First, after receiving a patient, orient your diagnosis through the medical history and physical exam. When arriving home, target the specific pathology with a book, such as Blueprints. Then, create your own treatment plan and see how it compares to the one the resident/attending chose.

Second, if there is flexibility in choosing the patients, find a patient with a pathology recently read. Afterward, habituate the pathology with the findings in the medical history and clinical exam specific for this patient (and the studied disease).

Tips for the Neurology Shelf Exam:

• In order to build momentum, take a quick first pass through the questions. Answer the easy ones, mark the ones you’re unsure of to review during the mini-breaks, and leave the questions you don’t know the answer to.
• To avoid making errors by moving through the questions too fast, take some mental breaks during the exam.
• For the questions you left blank, choose the most probable choice, or choose the answer you believe the test makers want you to.
• Regarding the question bank, start it as early as possible. Even if the content is unknown, the hypercorrection effect comes in handy when the real deal will be tested.
• The clinical mastery series of the NBME Self-Assessments is a good resource to utilize towards the end of your rotation.

Residency Choices: Pursuing the Neurology Specialty

Neurology is one of the most accessible specialties, as it’s the 15th specialty out of 22 in terms of competitiveness. The average Step 2 CK score amounts to 245. It not only has a low threshold, but it is also one of the few clinical specialties that offers the opportunity of procedures.

For example, after completing residency, you can specialize in interventional neuroradiology. This specialty solves cases such as ischemic or hemorrhagic strokes.

View our comprehensive Specialty Competitiveness Index, which assesses specialties based on USMLE Step 1, Step 2CK, Top 40 NIH, publications, and more.

With a four year residency path, neurology begins with a preliminary year, during which you will study internal medicine (IM) before the three core years of neurology. During PGY-2, the residency will focus on the inpatient clinic. PGY-3 will emphasize the outpatient clinic.

Learn more about whether or not the neurology specialty is right for you: So You Want to Be a Neurologist (video and article).

Final Thoughts on Neurology Clerkships

If you’ve already completed internal medicine, you can definitely ace your neurology rotation.

Acing your neurology rotation is a question of learning:

• How to ask the right questions during history taking.
• The basics of the neurologic exam (refer to Blueprints Neurology for it).
• The “bread and butter” pathologies (both reflected by your patient population and in the Shelf).

The neurology rotation may provide you with the chance to pursue research if that’s an interest of yours. Neurology is a medical specialty with a strong emphasis on research. According to our MSI index, the average applicant has seven presentations/publications.

There’s a lot to like about neurology. About 80% of neurology is outpatient, so you probably won’t have to work on the weekends and will instead have something like an 8-5 practice. Though it should be noted that most private practice neurologists have to be on call for local hospitals.

It’s also a great specialty if you enjoy building long-lasting relationships with patients. Since most neurological diseases are chronic, you’ll be working with many of your patients for months or years.

That being said, it’s also one of the most emotionally-challenging specialties—in terms of burnout, neurology consistently ranks at the top. Neurological diseases are debilitating and treatment options aren’t as prevalent or strong as in a specialty like cardiology. If you wish to pursue neurology, it’s essential that you are comfortable with palliative and hospice care.

Compensation for neurologists is also on the lower end, as they make an average of $280,000 a year. Training will also likely last for another five or six years after medical school, at least, as most neurologists pursue a fellowship due to the wide breadth of neurology.

Though it comes with its challenges, neurology is an ideal specialty if you want to pursue a career dealing with the most fascinating organ system in the human body. In just the last 20 years, we’ve seen astonishing improvements in our understanding of the brain and spinal cord. Improvements that are very likely to continue, as each year, neurological diseases are consistently in the top three most funded diseases by the NIH.

It’s a specialty that’s rapidly growing, and if you enjoy the complexity of neuroscience as well as using deductive reasoning and the physical exam to determine a diagnosis and treatment plan, neurology could be the specialty for you.

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