Satan, M.D.
5+ Year Member
Apr 16, 2014
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I'm a PGY-2. I feel like I've learned a lot so far this year, but I still feel like most of my knowledge as been learned by self-study & a few key attendings who put forth the effort to actually teach minutia & explain their reasoning. I feel like I am mostly teaching myself though. I feel like there are aspects of the neuro exam I am missing because I haven't been formally shown parts of it. When it comes to AEDs I'm only really comfortable with like 3 of them (basically only in the context of status) & don't know a good resource for learning specific applications/ADRs other than uptodate (I've only had 1 week of epilepsy to be fair). I don't think I can do a Dix-Hallpike (at least it hasn't worked once yet) of Epley maneuver. I'm still terrible at fundoscopic exams.

My institution is far from top tier, but it does have some VERY good attendings, but others that just go through the motions. I'm just worried that I'm not getting the most out of it & want to be exposed to as much as possible before going off on my own. Is this normal? I've been running through the Cheng-Ching neurology boards review book to learn. My goal is to nearly finish the questions by the end of the year. Is there anything else I can/should be doing?

Ibn Alnafis MD

10+ Year Member
Dec 26, 2008
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Seems to me that medicine, not only neurology, is mostly self-learning that continues till the end of your career. The best attending at my facility told me once that he leaned most of what he knows about neurology not during his residency/fellowship but during his first few years of attendinghood.

You’re not alone. I doubt there’s a any neurology program where they handhold you through every physical exam, test interpretation, or heated discussion with pts family.

Sometimes, certain knowledge/skills are only acquired if you actively seek after. From as simple as asking your attending to show you how to check for frontal release sign to having to do an elective to learn how to perform/interpret EMG/NCS.

I feel fortunate that at my program (low tier university program), bedside teaching is A+. Still, I do still find myself having to learn most of the things on my own. Many times, it’s assumed that we know these things. Why do we use PCC instead of FFP to control brain bleeds? Why do we keep SBP below 140 for ICH even though studies didn’t show difference between 140 vs 180? Etc

Professionally, I am the same age as you, so I don’t have much advice. However I’m “trusting the system” I guess. Just try to keep up with reading.
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If you wait for your attendings to spoon feed you neurology secrets to make you into a modern day Charcot, you'll keep waiting.

Look to the upper year residents. Pick the few that know what they're doing, and try to emulate them in thought and action. DItto the trusted and excellent attendings around you, but be wary of cults of neurology that form around some program directors and chairs. You are NOT a robot! Look to your other PGY2s for the same. Know that most differences you see are stylistic and there is no clear consensus on MANY aspects of care, from starting a new AED to escalating therapy in an MS patient to insisting on head position in a stroke patient. Right now you have to start developing your OWN style, your own decision-making. You do that by thinking hard about cases, where you agree and where you disagree with management.

The BEST training is to focus on your weak areas and make them stronger. Work hard, stay smart, be good to your team and to your patients. A lot of the training is in the non-intellectual or knowledge based aspects: how to work, how to be smart, how to be a good doc and good team member.
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In retrospect, I would say my residency education was 50/50 myself versus attendings teaching me. Subsequent to that, in the real world you actually keep educating yourself forever. And the fear and the pressure of being solo vastly speeds up the learning process.

Neurology is a complicated specialty that simply cannot be mass produced or easily speed performed and this works against teaching in overwhelmed academic services where time is precious. Burnout is very high in our specialty and this makes for a harder crunch on attending teaching, too.

Plus, some people are smarter than others, better teachers than others, better/kinder people than others, more selfless than others, and better at communicating and connecting with patients than others. It's just part of life. And finding those who are highly intelligent, good teachers, patient, etc is sometimes not easy. So you may want to take some time and care in selecting very specific people to learn from and just stick with them.

There is so much to say, but let me try this...

My advice to you is:

1) Learn how to do a neurological exam correctly. A real one. Correctly. Be careful you aren't just skipping through the motions. When is the nervous system working properly and when isn't it working properly. This is the foundation of what you are learning right now. Then when you ask for a sharp, very specific question about some subtle physical exam nuance you have a huge framework for baseline to add upon. Also, record what you did truthfully. "CNII-XII intact grossly" is just code that you didn't check all of them.

2) Later in residency do lots of outpatient rotations and work really hard trying to learn as much as you can when you do them - don't just use them as a vacation. And strategically pick the outpatient electives for maximum usefulness and benefit. Neuro residency is hugely inpatient. Status, stroke alert, rule out stroke, altered mental status, headache, etc. The majority of neurology is actually outpatient (unless you're into a neurohospitalist or neurointensive care-type job). So, you will actually have to do electives to spend time getting experience in a movement disorders clinic with Parkinson's medicine titrations, or a neuromuscular clinic doing EMG, or learning about medications for epilepsy maintenance.

3) Read read read read. It makes it a heck of a lot easier to remember anything - say MSA subtypes - after you've seen an actual case *and* read about them over 20 times. I printed dozens and dozens of the neurological CPCs from the New England Journal of Medicine and read them over, and over, and over, and over during residency. I *still* have a three foot stack of those printed CPCs in my library at home. Other than that I also read each Neurology Continuum issue when they came out. And the most important journal articles.

4) There is no substitute for working harder than everyone else, and being kinder and more patient than everyone else. These qualities will help you more than the rest of my list. No one can make you truly care and you can't fake it. If you honestly care enough it will shine through with hard work, kindness, and patience...and will make you much more approachable for teaching points.

Good luck to you. I know most of my post wasn't something you actually asked for, but it seemed to me that it would be helpful for you.

It gets better. A lot better. I promise.
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Jul 6, 2009
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You will never be able to get more than 10, MAYBE 20% of what you need sheerly through observation, lectures etc. Reading is incredibly important.

Be structured about it. Read about cases that you are seeing (it's amazing how even a few minutes can really make you feel much more comfortable about something esoteric, and look like a rock start). Keep a list of questions, things you don't know that you can look up--you shouldn't have to ask yourself the same question twice.

You also have to do more structured reading. Different strokes for different folks, but I probably learned 80% of my neurology from Continuum--this is an amazing resource. A good, outline type board prep guide.

Really, doing "okay" on rotations and passing the boards are a very low bar--you can and should strive for more as a resident. This will make your life as an attending, especially during the first few years--much easier. Luckily we chose a specialty in which the subject matter is inherently fascinating, which makes this much less of a chore.

Good luck!

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