Confidence in the neurological examination and exam avoidance among medical residents

Neurophobia is the fear of clinical neurology. Little research has explored how the neurological exam contributes to this fear. We wanted to better understand the confidence that medical residents have with the neurological exam and determine how confidence affects their examination of neurological patients.

This was a single-centre study in which Internal Medicine and Family Medicine residents rated their confidence in conducting different aspects of a neurological evaluation through a self-administered survey. Low confidence was defined as a score of ≤3 on a 5-point Likert scale. Participants also rated the likelihood of their peers skipping a relevant exam for patients presenting with neurological, cardiac, respiratory, gastrointestinal, or musculoskeletal complaints. Free form responses were sought to understand reasons for skipping.

There were 97 respondents (35 IM; 61 FM), out of a total of 350 eligible participants. 36 were first year, 45 were second year, and 14 were third year residents. Participants were least confident in localizing (Median = 3; IQR 2-4) and forming a differential (Median 4; IQR 3-4). Confidence did not improve with additional years of training and respondents felt increased exposure to neurology and more teaching would improve their confidence. Participants felt their peers were most likely to skip a neurological (Median = 3; IQR 2-3) or musculoskeletal exam (Median 3; IQR 2-4). Likelihood of skipping part of a neurological exam increased from post-graduate year one to two. Low confidence and lack of time were cited as major contributors.

Residents appear to be less confident in conducting the non-physical aspects of the neurological exam, including localizing and forming a differential. Low confidence was a major contributor to residents forgoing a neurological exam. More teaching and exposure to neurology were the most common self-reported factors that would improve resident confidence in the physical exam.