This study demonstrates the positive effects of didactic teaching sessions on medical student test performance in a Neurology Clerkship. The students also expressed a greater degree of satisfaction with their clerkship experience as well. Several issues merit discussion.
Sub-group analysis demonstrated that the significant improvement was primarily attributable to the third-year students. This is particularly notable because there were significantly fewer fourth-year students in the post-intervention group. It is generally assumed that fourth year students would test better than third year students given one more year of clerkship and clinical experience. If this were true, the teaching intervention would have to be especially effective if the average test score improved in the post-intervention group given the higher proportion of third year students in the latter. Although the third-year students performed less well than their fourth-year counterparts before the intervention, no statistically significant difference between third and fourth year students could be detected after the intervention. Moreover, the average score of the third year students was marginally better than the fourth-year student scores after the educational intervention. For these reasons, the data indicate that student test performance can be improved with didactic teaching sessions such that a third year medical student will perform as well as a fourth year student in a neurology clerkship.
Although statistically significant, the increase in aggregate test scores was not marked; 74% versus 76%. Despite the students being given various types of study materials, (e.g. study guidelines, PowerPoint summaries and didactic sessions), they still continued to select a wrong answer 25% of the time. This may be a cause for concern as the students were given an examination specifically designed to test neurological emergencies and commonly encountered neurological diagnoses. These results suggest that ongoing continuing medical education in neurology may be necessary in order to insure that these concepts are retained during post-graduate medical practice. A previous report noted that orthopedic surgery residents who took additional subspecialty elective training as a medical student continued to outperform their peers both as first year and as chief residents (Freeman KB Journal of Bone and Joint Surgery 1998) [
4]. For this reason; we recommend that other clerkships make a concerted effort to re-emphasize basic concepts learned in other core clerkships in addition to their own.
We recommend exposing students to a required neurology clerkship in the third year for a variety of reasons. First, our study demonstrated that the didactic teaching sessions compensated for the difference in clinical experience between the third and fourth year students. Earlier exposure to this specialty might also increase the number of medical students who choose neurology as a specialty. One article projected that our nation will have only 60% of the neurologists needed by the year 2010 (Kurtzke JF Neurology 1986) [
5]. Therefore, many patients will rely on non-neurologists to recognize and treat common neurological illnesses and emergencies. For this reason, any method that improves a student's knowledge and clinical skills in this discipline should be initiated. Exposure to neurology earlier in the medical school curriculum would provide additional opportunities for neurology instruction in related specialties during the students' fourth year even for students who do not choose to practice neurology.
The medical students' perception of the quality of their education is also important although it is less quantifiable. Student feedback regarding these didactic teaching sessions was almost uniformly positive. Specifically, the students were of the opinion that they were exposed to a wider range of subject material. However, a review of their direct patient exposure revealed a strong bias towards inpatient disorders such as stroke and seizure disorders. Because neurology is primarily an outpatient and consultative specialty, students who do not received targeted, didactic instruction may not develop a clinical approach to common neurological disorders such as vertigo, headache, and neuromuscular diseases, which are generally treated on an outpatient basis. However, we are of the opinion that these didactic sessions should address actual case histories so that the students are given examples of patients that will be encountered in clinical practice. These sessions allow a clinician to explain the clinical reasoning process as well as the salient features of the disease process.
There are several limitations of this study that merit discussion as well. This was a study that was purposefully conducted retrospectively. Despite the limitations of a retrospective study, a prospective study of student test score performance would have not necessarily been superior and may have raised some ethical issues. When students know that they are being observed for test performance, the confounding variable of a “Hawthorne effect” cannot be excluded. Furthermore, medical education presumes that all students should be given equal access to educational opportunities. It may be unethical to conduct a trial in which students were randomized to receive didactic instruction or no instruction at all. This may be especially true for students applying to competitive specialties that require maximizing one’s grade point average. Another limitation regards the accuracy of historical controls. The pre-intervention group differed in that fourth year students were more highly represented. However, these students tend to have more medical knowledge, clinical reasoning skills and better test-taking skills than their third year counterparts. Nonetheless, the superior performance of the post-intervention group, comprised mostly of third year medical students, make this study’s findings even more remarkable. This study did not address alternative educational methods such as “e-learning” or simulated patients. While these methods may be beneficial as well, the student feedback clearly indicated that they perceived a superior educational experience when being instructed by a clinical neurologist.
In conclusion, a twice-weekly didactic teaching session based upon actual patient case histories improved final neurology clerkship examination scores and overall student satisfaction. A multi-institutional study that would confirm the results of this pilot study is warranted. Similar studies conducted in other medical specialties are also indicated in order to validate this study.