Demystifying neurology

Phenomenology can help

See Reviews p 1528

Muhammad Ali, Dudley Moore, Ronald Reagan, and Christopher Reeve have in common that they suffered from degenerative and traumatic disorders of the nervous system, the prevalence of which will increase greatly during the next 20 years.1 Although neurological and psychiatric disorders account for only 1.4% of all deaths, they account for a remarkable 28% of all years of life lived with a disability. Thus all doctors must be prepared to meet the needs of patients with such disorders and refer appropriately for specialised care and investigations, bearing in mind that neurologists often function as consultants for other physicians. Yet do medical students and house officers believe they are being adequately prepared for independent practice, and do general doctors have confidence in their ability to diagnose and treat patients with disorders of the nervous system?

Apparently not. Schon et al recently surveyed medical students, senior house officers, and general practitioners about such matters, and the results merit serious attention.2 Compared with their knowledge of other organ systems, their knowledge of disorders of the nervous system was said to be poorest. Moreover, basic neuroscience and clinical neurology ranked at the top of the list for difficulty in learning and complexity. Practising doctors likewise averred that they had less confidence in practical clinical situations in neurology than in other system disorders. When respondents to the survey were asked to identify the causes of their difficulties in neurological education, they cited insufficient, poor, irrelevant, or poorly coordinated teaching, and intimidation by neurology's reputation as a tough grind, among other considerations. Although the survey was carried out in the United Kingdom, few neurologists and educators elsewhere would doubt the universality of these disturbing findings, which were in fact identified in the United States and Canada a generation ago. 3 4

Many groups, including the World Federation for Medical Education, the Royal College of Physicians of London, and the American Academy of Neurology, have weighed in with proposals and remedies. 5 6 Everyone agrees that the teaching of basic neuroscience and clinical neurology must be more effectively integrated, that sufficient time for neurology must be allotted in an already overburdened curriculum, and that every practising doctor must be prepared to handle common neurological disorders and emergencies. Neurologists are also discovering that there are reciprocal benefits for teaching and patient care from collaboration with other groups. For example, advances in neuroscience research have now made it untenable to draw a sharp demarcation line between the twin educational domains of neurology and psychiatry, and the Department of Mental Health and Substance Dependence of the World Health Organization has inaugurated a collaboration to grapple with these and related issues. In the United States, neurological teachers have also joined forces with their counterparts in primary care to develop and implement a family practice curriculum in neurology, intended to enlarge the range of settings in which educational programmes are carried out (CD Rom available from the American Academy of Neurology, kjones{at}aan.com).

About 50 years ago, Morris B Bender rightly concluded that the bottom up pathway in neurological education—from basic science to clinical problems—was becoming dysfunctional and instituted a top down approach starting with clinical signs instead, by means of phenomenology seminars. In origin, as described by philosopher Edmund Husserl, phenomenology is the intuitive appreciation of phenomena as they are immediately perceived, without reference to scientific theory or prior learning.7 Teaching phenomenology in neurology rivets the attention of learners to an arm that shakes, an incomprehensible word, or a person lost in the world. Explanations and interpretations “to save the phenomena” follow, but do not precede or coincide with, awareness. Clearly, phenomenology is an approach that starts with the patient's perspective (illness) and only later shifts to the doctor's perspective (disease). Such teaching shifts emphasis from the passive methods so widespread in medical education to more active, self directed, and independent study.5

The a priori method of phenomenology represents a radical departure from the prevailing educational paradigm of the 20th century. This general approach, with neurology as an example, is possibly applicable in other clinical fields. As there are fewer born teachers than born poets, however, success hinges upon the availability of adequate resources to promote and sustain a cadre of seminar leaders who are both content experts and teachers trained as educators.5