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13TEACHING NEUROLOGY AND NEUROPHOBIA AMONG STUDENTS
Vasylieva N.
MD, PhD
HSEEU "Bukovinian State Medical University", Chernivtsi Department of Nervous Diseases, Psychiatry and Medical Psychology
ABSTRACT
Clinical teaching is not about the passive of transfer of knowledge from teacher to student. The challenge of imparting a large amount of knowledge within a limited time period in a way it is retained, remembered and effectively interpreted by a student is considerable. This has resulted in crucial changes in the field of medical education, with a shift from didactic teacher centered and subject based teaching to the use of interactive, problem based, student centered learning. Traditionally, the subject of neuroscience and clinical neurology has been one of the most difficult courses for medical students in undergraduate medical education.
Keywords: teaching, neurology, medical students, neurophobia.
Nowadays, a new educational system is being established. This is accompanied by significant changes in the pedagogical theory and educational practice. The educational paradigm is changed; a new content of education is offered. Traditional ways of presenting information are replaced by new types of visualization, computer means of teaching, different interaction between the teacher and the student, etc [1]. The instrumental nature of the vocational education methodology is discussed and debated within the framework of technologies and innovation in education. New concepts are created to comprehend the changes in opinions regarding the theory, methodology, and technology of teaching [2]. Therefore, the teaching process in pedagogical high schools requires an organization that would make the student a subject of educational activity. This approach pays special attention to the individuality of the student. In the context of studying the personality traits of students, consideration of the individual types of perception of educational information is significant.
However, the principle of individualization often remains on paper only, while either lacking in practice altogether or being purely formal. The teacher develops and offers students individual assignments based on his or her own style of pedagogical activity [3]. This can cause frustration and anxiety in students and make it impossible for them to choose ways of learning freely. The quality of education in high school is discussed within the framework of technologies and innovation used in the educational process. New concepts are created to comprehend the changes in opinions regarding the theory, methodology, and technology of teaching.
A clinical teacher's main job is to equip students with an enthusiasm to learn neurology. Clinical teaching is not about the passive transfer of knowledge from teacher to student. Good teachers inspire, entertain and support their students in their learning. The word "educate" (from Latin "e" + "ducere", to lead out), like the word "educe", means to "bring out, develop from a latent condition". The word "train" (from Latin "trahere", to draw out) refers to dragging or trailing something, usually behind you. Clinical teaching is about bringing out, not dragging behind; dogs and horses can be trained but medical students also need to be educated. Clinical teachers are privileged to teach students who are, by selection, among the most intelligent and highly motivated in the country; so a failure for them to learn
is the fault of the teacher and not the student. Some teachers feel that their job is to lay out polished pearls of wisdom and then call students "swine" if they do not appreciate the beauty of the offering. Students will be bored and therefore not learn from teacher if teacher is boring as a teacher, no matter how pretty he thinks his pearls are. Many excellent teachers have had no training in teaching but bad teachers can be improved to reasonable teachers by being taught to teach. Everyone's teaching can be improved with reflection upon what they are doing when they teach. The good clinical teacher will teach with the students' perspective in mind.
Learning clinical medicine is a process of the progressive layering on of knowledge and skills, like a clay sculpture which only has the vague frame of a shape before the full form becomes evident as successive pieces of clay are applied and integrated with the final form. No one appreciates an art master who constantly rubbishes your efforts at sculpture; learning the joys of clinical medicine should be a positive experience, even if one's early efforts are misshapen. There are many ways of teaching successfully and different styles of teaching suit students with different styles of learning [4]. However, there are some principles by which most good teachers are guided:
- know what the students might be expected to know already, that is, what stage they are in their course;
- know, and let them know, what you expect students to learn in their time with you (educators call these 'learning objectives');
- encourage active learning through problem solving rather than passive fact accumulation. Relevant facts will accumulate through the problem solving activities;
- criticism should be constructive. Bullying students is seen as a sport by some teachers but does nothing of educational value for the victims.
Dunn et al. [5] defined the term 'learning style' as different and unique ways used by individuals as they prepare to learn and recall information. Educational theory suggests that clinical experience and success at examinations bears a relationship to learning styles.
Most clinical teachers are happiest with the 'So-cratic' style of teaching in small groups, which is offered by ward rounds and clinics. This is the mode of
teaching that medical students appreciate the most too. Most clinicians are least happy giving didactic lectures, which in turn probably have the least educational value to clinical students.
Ideally, clinical teaching should be with actual patients but changes in clinical practice can make this difficult, so it is wise to have some virtual patients to show on our laptop or tablet; videos of patients with abnormal eye movements and movement disorders are particularly good for this. Problem solving can only be learnt through experiencing the task of solving problems with the teacher as a knowledgeable guide. In neurology, interviewing and examining the patient are crucial skills in both diagnosing and excluding a disease, as well as in the follow-up of disease progression. There is a need to develop effective educational experience in neurology as it has been reported that students experience neurology as a difficult topic, and some ascribe this to insufficient knowledge and poor teaching. By the time neurologists meet clinical students they will have encountered much clinically relevant neuroscience, usually hidden among much clinically irrelevant neuroscience. They can be guided to recover sight of the relevant wood from the trees and use their knowledge to solve a clinical problem.
In teaching how to examine the nervous system a clinical teacher comes up against one of the pillars of neurophobia [6]. "Neurophobia," a term coined in 1994 by Dr. Ralph Jozefowicz, a professor of neurology in the United States, is, unfortunately, a well-documented global phenomenon. It is an endemic chronic "disease" among medical students and junior doctors. How can we understand the genesis of neurophobia? This untoward educational phenomenon quintessentially reflects medical students' daunting perceptions and beliefs, their negative preconceptions associated with neurological education, their apprehensive emotional sentiments of neuroanxiety, dislike, intimidation, and eventual disinterest emanating from their perceived difficulty to apply basic science knowledge to clinical scenarios. Students with neurophobia express their "fear of neurology" as:
- neurology to be ranked as far more difficult than any other discipline in a theoretical context;
- having less comfort and least confidence to handle neurology "at the bedside" in clerking neurology patients;
- neurology to be the discipline where they felt least knowledgeable about since the integration of basic neurosciences was not early during their clinical training, and to have inadequate and less frequent clinical neurology exposure;
- avoidance of examination of the nervous system and a cynical and nihilistic attitude toward neurological diseases.
The students always look relieved when I tell them that no one ever completes a 'full neurological examination' (even if anyone knows what this is). I ask the students to think about why they are examining the nervous system, since only then will they be able to say what they want to examine. Then I ask them what reasons there might be for examining patients, ending up with the following list:
- to test diagnostic hypotheses generated from history taking;
- screen for unsuspected neurological signs;
- baseline for the future (eg, in a patient thought to have Guillain-Barré syndrome: 'yesterday he did have arm reflexes today he doesn't');
- give some time to think about the history and management while the patient is not supposed to be talking;
- because the patient expects it (it is what doctors do) and it gives him/her the perception student have taken their problem seriously. Students usually quickly supply the first three reasons but need more help in arriving at the last two.
I then ask them to develop a neurological screening test, which with guidance ends up looking like the one I use in the clinic. I then point out that like all screening tests, they need to know what abnormalities this screen could miss (ie, have a feel for the sensitivity and specificity). I tell them that I expect them to become confidently competent in this because this may be the only neurological examination they ever subsequently use. The opportunity to understand more complex signs comes later as they go through their clinical experience but a few signs I do specifically make sure they can cope with:
- difference between upper and lower motor neuron lesions;
- significance of nystagmus;
- third and sixth cranial nerve palsies (complete ptosis is third nerve palsy or myasthenia) and internuclear ophthalmoplegia ("the only subtle sign in neurology which has anything other than subtle significance is the perceptible slowing of adduction on horizontal saccades");
- how to see the optic discs and recognise normal fundi;
- different gaits (hemiplegic, Parkinson's, spastic, neuropathic, ataxic, myopathic etc). By the way, most neurologists can act these out if the right patients are not available;
- the difference between "confusion" and fluent dysphasia or dysarthria.
While teaching students with patients, clinicians are unavoidably teaching them attitudes towards patients. If you teach on a patient as an object with clinical signs, you are encouraging students to dehumanize their patients. So I make sure that the patients remain involved, usually with a bit of banter and apologies for "treating your legs (etc) like lumps of meat", and the like. I also ask the patient at the end of the session if he/she has any questions arising from the session and then get the students to answer, thereby testing their communication skills (and mine). I also emphasize to the students that one must evolve a "patter" to communicate to the patient what is required of the patient being examined neurologically ("remember when we examine their nervous system, we do get patients doing things which must seem pretty strange to them!"). Thus, students will learn that to communicate adequately with patients you have to see the situation from "the patient's perspective" and this applies even to examining them neurologically. Similarly, a lot of our
neurology outpatient work involves explaining things to patients and students will learn how to explain difficult neurological phenomena to patients from your example, so make it good!
No matter how many times they are told, students take a long time to appreciate that most of the skill in neurology is eliciting (or educing) a good history. They should learn that while anatomy and physiology are used to decide where the lesion is, the history is essential in determining the pathology. One way in which I demonstrate how impossible it is to get to a diagnosis without a history (and often how impossible it is not to have any history) is by asking students to make a diagnosis only from the examination findings. So, at the end of 30 min or so of examining different parts of a patient's nervous system, after we have elicited all the signs and know that the patient has a spinal cord lesion, I ask a student to ask one question about the history ("because of healthcare rationing only one question allowed"). This means that students have to think about what the most discriminating question might be (it is usually 'how and how long ago did this all come on?"). An alternative way of teaching the value of the history is to ask the patient to recount their history warning them that you will be interrupting them repeatedly to ask the students what they think is going on. Then after every few sentences, ask the students what they think the diagnosis is. But first I ask a student what the diagnosis is before the patient starts talking. Here the student has to use the patient's evident age and gender as well as any clues around the bed to start hypothesizing using epidemiologically based a priori likelihoods. This demonstrates the active way in which we think of the history, hypothetical diagnoses rising and falling in our minds as the story unfolds. If this type of exercise is put next to the one above, it can be shown that analyzing
the history gets the answer much quicker than just examining the patient (or just doing a scan for that matter).
References
1. Kahraman, H.T., Sagiroglu, S. & Colak, I. Development of adaptive and intelligent web-based educational systems. In 4th International Conference on Application of Information and Communication Technologies. AICT 2010, 227-230.
2. Kudliskis, V. Teaching assistants, neuro-lin-guistic programming (NLP) and special educational needs: "reframing" the learning experience for students with mild SEN. Pastoral Care in Education, 2014. 32(4), 251-263.
3. McCusker, K.A., Harkin, J., Wilson, S. & Cal-laghan, M. Intelligent assessment and content personalisation in adaptive educational systems. In 2013 12th International Conference on Information Technology Based Higher Education and Training, ITHET, 223232.
4. Lasitha Samarakoon, Tharanga Fernando, Chaturaka Rodrigo & Senaka Rajapakse Learning styles and approaches to learning among medical undergraduates and postgraduates BMC Medical Education. 2013. 13:42 http://www.biomedcentral.com/1472-6920/13/42.
5. Dunn R., Giannitti M.C., Murray J.B., Rossi I., Geisert G., Quinn P.: Grouping students for instruction: effects of learning style on achievement and attitudes. J Soc Psychol 1990, 130(4):485-494
6. Flanagan E., Walsh C,. Tubridy N. 'Neuro-phobia'-attitudes of medical students and doctors in Ireland to neurological teaching. Eur J Neurol 2007;14:1109-12.
ИНТЕРАКТИВНЫЙ МЕТОД КАК ПЕДАГОГИЧЕСКАЯ ИННОВАЦИЯ В ВЫСШЕМ
МЕДИЦИНСКОМ ОБРАЗОВАНИИ
Залявская Е.В.
Высшее государственное образовательное учреждение Украины "Буковинский государственный медицинский университет",
Черновцы, Украина
THE INTERACTIVE METHOD AS AN EDUCATIONAL INNOVATION IN HIGHER MEDICAL
EDUCATION
Zaliavska O.
Higher State Educational Establishment of Ukraine "Bukovynian State Medical University", Chernivtsi, Ukraine
АННОТАЦИЯ
Метод интерактивной технологии обучения - метод конкурентных групп, представлен в статье, способствует активному внедрению междисциплинарной интеграции в обучение, развивает у студентов умение самостоятельно создавать собственный подход к получению, анализу информации, формирование интегрированных выводов и собственного опыта, клинического мышления, умение отстаивать свою точку зрения в интеллектуальном пространстве.
ABSTRACT
The method of interactive learning technology, the method of competitive groups, presented in the article promotes the active implementation of interdisciplinary integration in learning, develops students' ability to create
