American Academy of Neurology Clinical Skills Examination Training Program

© 2011 AMERICAN ACADEMY OF NEUROLOGY

American Academy of NeurologyClinical Skills Examination

Training Program

(date)

(speaker)

(association)


Goals of this session

• Understand the American Board of Psychiatry and Neurology (ABPN) performance requirements for the five Clinical Skills Evaluations (NEX) neurology residents must pass to achieve board certification.

• Appreciate the difference between a grade of ACCEPTABLE and BORDERLINE BUT UNACCEPTABLE.

• Improve the inter-rater reliability of faculty evaluators for acceptable versus unacceptable distinctions.


What is your role within your department?

1. Department chair

2. Residency program director

3. Adult neurology faculty

4. Child neurology faculty

5. Resident

6. Fellow

7. Other1 2 3 4 5 6 7

0% 0% 0% 0%0%0%0%


For how many years have you been practicing as a neurologist?

(Only faculty with a clinical appointment should answer.)

1. 0-4

2. 5-9

3. 10-14

4. 15-19

5. 20-24

6. 25 or more1 2 3 4 5 6

0% 0% 0%0%0%0%


Have you ever served as an ABPN oral board examiner?

(Only faculty with a clinical appointment should answer.)

1. Yes

2. No1 2

0%0%


For how many NEX examinations have you served as a faculty evaluator? (Only faculty with a clinical appointment should answer.)

1. 0

2. 1-4

3. 5-9

4. 10-14

5. 15-19

6. 20 or more1 2 3 4 5 6

0% 0% 0%0%0%0%


How confident are you that you understand the ABPN criteria for determining whether a resident's performance on

an NEX merits a passing grade?

1. 1 – Not at all confident

2. 2

3. 3

4. 4

5. 5

6. 6

7. 7

8. 8

9. 9

10. 10 - Extremely confident

1 2 3 4 5 6 7 8 9 10

0% 0% 0% 0% 0%0%0%0%0%0%


Neurology Clinical Evaluation Exercise (NEX)

•Every resident must pass an examination in each of 5 categories during residency to sit for the neurology written board exam. AmbulatoryCritical careNeuromuscularNeurodegenerativeChild neurology (for adult neuro residents) or adult neurology (for child neuro residents)


Why train faculty evaluators?

•ABPN oral board examiners underwent training

•Poor inter-rater reliability between former ABPN oral board examiners and local faculty. (Schuh, et al 2009)



What constitutes a pass or fail?

5 (marginal pass)

•Deficiencies or errors in history or exam, but enough information is obtained to formulate the case.

4 (marginal fail)

•Deficiencies or errors in history or exam, which result in the resident not being able to successfully formulate the case.


Clinical Skills Examination Training (CSET) Program

Designed by a workgroup through the Consortium of Neurology Program Directors.

Objectives:Create a simple NEX training program that

can be utilized by faculty at neurology training programs

Focus on pass-fail distinction


Clinical Skills Examination Training Program - Instructions

• We will review a series of 9 brief vignettes. For each, there will be an example of an omission on the part of the resident.

• Assume that the resident has performed a basic history and physical examination that is otherwise adequate

• Select PASS or FAIL based on whether the omission is egregious enough to warrant an overall failing grade.

• Review audience votes, as well as the voting results and talking points from previous participants.

• Open discussion (Up to 1 minute for each side.)• Re-vote


Objectives

•Distinguish between those mistakes and omissions that interfere with the formulation of the case.

•Training through reflection and discussion•Data gathering


Criteria for assigning a failing grade

•Deficiencies or errors in history or exam which result in the resident not being able to successfully formulate the case.



Critical Care Scenario: (PRE)A 55 year old woman with known myasthenia gravis is

admitted to the intensive care unit with a chief complaint of shortness of breath and generalized

weakness.

Omission:The resident does not check neck flexion strength.

1. Pass

2. Fail

1 2

0%0%

Historical Pass Rate: 76.2% (n=101)

Talking points:Pass: Helpful, but not crucial. Respiratory parameters are crucial.

Fail: Might help me determine whether or not to intubate.


Critical Care Scenario: (POST)A 55 year old woman with known myasthenia gravis

is admitted to the intensive care unit with a chief complaint of shortness of breath and generalized

weakness.

Omission:The resident does not check neck flexion strength.

1. Pass

2. Fail

1 2

0%0%


Talking points:Pass: Helpful, but not crucial. Respiratory parameters are crucial.

Fail: Might help me determine whether or not to intubate.


Pediatrics Scenario: (PRE)A 6 year old boy with normal birth and

development develops progressive difficulty walking and climbing stairs. His calves are

large.

Omission: The resident does not ask about family history.

1. Pass

2. Fail

1 2

0%0%


Talking points:Pass: Won’t affect workup.Fail: Family history can direct DNA testing


Pediatrics Scenario: (POST)A 6 year old boy with normal birth and development develops progressive difficulty walking and climbing

stairs. His calves are large.

Omission: The resident does not ask about family history.

1. Pass

2. Fail

1 2

0%0%


Talking points:Pass: Won’t affect workup.Fail: Family history can direct DNA testing


Neuromuscular Scenario: (PRE)A 37 year old woman, previously healthy, presents to

your office complaining of progressive muscle weakness and intermittent double vision.

Omission:The resident does not stabilize the elbow joint when

checking triceps strength.

1. Pass

2. Fail

1 2

0%0%


Talking points:Pass: This is a good teaching point, but doesn’t affect formulation.Fail: Poor exam suggests resident would not be able to properly assess in the future.


Neuromuscular Scenario: (POST)A 37 year old woman, previously healthy,

presents to your office complaining of progressive muscle weakness and intermittent double vision.

Omission:The resident does not stabilize the elbow joint

when checking triceps strength.

1. Pass

2. Fail

1 2

0%0%


Talking points:Pass: This is a good teaching point, but doesn’t affect formulation.Fail: Poor exam suggests resident would not be able to properly assess in the future.


Neurodegenerative Scenario: (PRE)A 75 year old woman is brought to your office by her

daughter for evaluation of mild memory loss.

Omission:The resident does not ask about educational

background.

1. Pass

2. Fail1 2

0%0%


Talking points:Pass: If cognitive function is declining, level of education doesn’t matter.Fail: This is important to give the physician a frame of reference.


Neurodegenerative Scenario: (POST)A 75 year old woman is brought to your office by her

daughter for evaluation of mild memory loss.

Omission:The resident does not ask about educational

background.

1. Pass

2. Fail1 2

0%0%


Talking points:Pass: If cognitive function is declining, level of education doesn’t matter.Fail: This is important to give the physician a frame of reference.


Ambulatory Scenario: (PRE)A 26 year old pregnant woman presents with a 3 week

history of bilateral hand paresthesias.

Omission:The resident does not check lower extremity reflexes.

1. Pass

2. Fail 1 2

0%0%


Talking points:Pass: This is probably carpal tunnel syndrome.Fail: Although unlikely, a cervical myelopathy needs to be excluded.


Ambulatory Scenario: (POST)A 26 year old pregnant woman presents with a 3 week

history of bilateral hand paresthesias.

Omission:The resident does not check lower extremity reflexes.

1. Pass

2. Fail 1 2

0%0%


Talking points:Pass: This is probably carpal tunnel syndrome.Fail: Although unlikely, a cervical myelopathy needs to be excluded.


Critical Care Scenario: (PRE)A 75 year old woman presents to the emergency

department with sudden onset of right sided weakness and slurred speech.

Omission:The resident does not check for a Babinski sign.

1. Pass

2. Fail1 2

0%0%


Talking points:Pass: Not part of the NIH stroke scale. Fail: This is necessary to localize the lesion.


Critical Care Scenario: (POST)A 75 year old woman presents to the emergency

department with sudden onset of right sided weakness and slurred speech.

Omission:The resident does not check for a Babinski sign.

1. Pass

2. Fail1 2

0%0%


Talking points:Pass: Not part of the NIH stroke scale. Fail: This is necessary to localize the lesion.


Neuromuscular Scenario: (PRE)Hospital consultation to see a 21 year old man with a

history of progressive ascending weakness.

Omission:The resident does not ask about recent vaccinations.

1. Pass

2. Fail

1 2

0%0%


Talking points:Pass: Wouldn’t affect diagnosis or management.Fail: A recent vaccine could be an immunologic trigger for this.


Neuromuscular Scenario: (POST)Hospital consultation to see a 21 year old man with a

history of progressive ascending weakness.

Omission:The resident does not ask about recent vaccinations.

1. Pass

2. Fail

1 2

0%0%


Talking points:Pass: Wouldn’t affect diagnosis or management.Fail: A recent vaccine could be an immunologic trigger for this.


Pediatrics Scenario: (PRE)A 12 year old boy presents with repetitive movements

of one hand.

Omission: The resident does not take a medication history.

1. Pass

2. Fail

1 2

0%0%


Talking points:Pass: Not likely to be relevant in a child.Fail: Medication-induced movement disorder is on the differential.


Pediatrics Scenario: (POST)A 12 year old boy presents with repetitive movements

of one hand.

Omission: The resident does not take a medication history.

1. Pass

2. Fail

1 2

0%0%


Talking points:Pass: Not likely to be relevant in a child.Fail: Medication-induced movement disorder is on the differential.


Ambulatory Scenario: (PRE)A patient presents with chronic, episodic vertigo.

Omission:The resident does not ask about hearing loss.

1. Pass

2. Fail

1 2

0%0%


Talking points:Pass: Wouldn’t affect work up or treatment.Fail: Vestibular tumor or Ménière’s disease are considerations


Ambulatory Scenario: (POST)A patient presents with chronic, episodic vertigo.

Omission:The resident does not ask about hearing loss.

1. Pass

2. Fail

1 2

0%0%


Talking points:Pass: Wouldn’t affect work up or treatment.Fail: Vestibular tumor or Ménière’s disease are considerations


Session complete


How confident are you that you understand the ABPN criteria for determining whether a resident's

performance on an NEX merits a passing grade?

1. 1 – not at all confident

2. 2

3. 3

4. 4

5. 5

6. 6

7. 7

8. 8

9. 9

10. 10 – Extremely confident

1 2 3 4 5 6 7 8 9 10

0% 0% 0% 0% 0%0%0%0%0%0%


Developed by the AAN Clinical Skills Examination Training Workgroup

Zach London, MDJoe Kass, MDVicki Shanker, MDSonja Potrebic, MD, PhDYousef Mohammed, MDGauri Pawar, MDRachel Ditrapani, MDRyan Walsh, MD

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American Academy of Neurology Clinical Skills Examination Training Program

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