Neurology has traditionally been perceived as one of the more difficult clinical sub-specialties and as such the term neurophobia was coined to describe 'the fear of neural sciences and neurology among medical students and doctors'
]. Though originally unsubstantiated by scientific data, the last few years has brought a renewed focus upon the teaching of neurology and more empirical studies seeking to address this issue [9
Our medical school was established in 1989 and currently has an intake of approximately 200 medical students annually. Its curriculum has followed a traditional British model with a preclinical phase lasting 3 years and a clinical phase lasting 2 years before graduation and internship. Since its inception it has inculcated Problem Based Learning (PBL) as a core teaching methodology, especially during the preclinical years, designed to give students early introduction to clinical scenarios and improve their critical thinking and decision making skills. This was hoped to bear fruit in the clinical years and one recent study notes that it has at least 'broken even' [12
We report that despite a PBL approach in the pre-clinical years our students still ranked neurology as the most difficult of seven medical sub-specialties by a fairly substantial margin, with approximately one quarter of all students indicating they found neurology very difficult. Similar results have been reported in other studies out of the United Kingdom and Ireland [2
]. Interestingly it was suggested that increasing the PBL component of the curriculum could be one means of helping to address this situation but our results indicate that PBL by itself will not adequately address the situation.
These results were borne out when students were asked to assess the subject that they felt they had least knowledge in and neurology again scored unfavorably, having the lowest mean. Coupled with the perceived difficulty associated with neurology these findings may have significant implications. Schon et al
(2002) were able to extend their study to include junior doctors and it was noted that they had least confidence when dealing with neurological cases 'at the bedside' [3
]. This suggests that attitudes and perceptions developed in medical school may have the tendency to spill over into clinical practice. Alternatively doctors' lack of confidence may be the result of inadequate training that if remedied would greatly improve performance on graduation. Whatever the case the onus is upon the academic staff to address these issues and ensure that students feel more empowered to deal with neurological cases.
Ridsdale et al
(2007) examined the possible effects of neurophobia in clinical practice within the United Kingdom. They noted that neurological diseases are increasing among the general population and this coupled with a lack of confidence among general practioners often results in over referrals to specialists [4
]. At the same time, the UK had the lowest number of neurologists per captia in Europe, an issue that is also of some concern in the Caribbean. In essence we may have a dilemma where neurophobia creates fewer specialists but then also places more demand on the few that do exist.
The onus therefore must be on improved training of our medical graduates. In fact we observed that neurology was not recorded as the discipline in which students had least interest coming ahead of respiratory medicine and psychiatry (though it is worth noting that the latter is a neuroscience based discipline) a finding similar to other studies [3
]. When students were themselves asked to indicate why neurology proved to be so difficult two factors stood out: the need to know basic neuroscience and the complex clinical examination. These were underscored by the responses to a similar open ended question in which students requested more time for neuroscience and neurology teaching and more clinical/practical exposure.
Within our context basic neuroscience is taught as an eight week course in the second year of medical school. Though heavily drawing on PBL it seems to suggest that this not enough time for the students to assimilate the material required. Neurology is taught in the clinical years but not as an independent clerkship; rather it is bundled inside of the larger medicine clerkship. This arrangement for teaching neuroscience and neurology may lack focus and based on our results does not allow enough time for assimilation of the material taught.
Data from the recently formed GKT Medical School in London (the largest medical school in the United Kingdom) suggest that if more time is allocated to teaching of neurology and neuroscience and this is coupled to focused course objectives, neurophobia is reduced. Students though, still perceived neurology as a difficult subject and lacked confidence in approaching problems [4
]. Other approaches to improve neurology teaching using case-based teaching in Australia [13
] and teaching videos in Singapore [14
] have also met with some success.
These interventions are clearly not complete solutions in themselves but represent movement in the right direction. They suggest that modifications in curriculum and teaching methodology can have a positive effect upon learning and such practices should be considered elsewhere. They also highlight that in our context, though PBL has brought with it some success, there is still a need to evaluate and bring refinements consistent with latest pedagogical data. Ultimately though, neurology as a sub-specialty may indeed be more difficult than other subjects and teachers must simply take the time and use all resources available to ensure adequate learning takes place.
Finally it may be worthwhile considering the perception students have of various subjects upon entering medical school. A recent study in the Caribbean noted a definite bias against psychiatry [8
]. In a similar manner perceptions of neurology may have nothing to do with teaching or curriculum but may be the results of societal stereotypes that need to be addressed in a more broad sense as a part of the overall solution. A British Medical Journal (BMJ) editorial describes "the neurologist is one of the great archetypes: a brilliant, forgetful man with a bulging cranium....who....talks with ease about bits of the brain you'd forgotten existed, adores diagnosis and rare syndromes, and – most importantly – never bothers about treatment."
Schon et al
even suggests that such a reputation is possibly enjoyed and encouraged by neurologists who like the notion that neurology is a discipline for which only 'young Einsteins need apply'
]. Such stereotypes clearly are not consistent with the future of neuroscience and neurology and the emerging clinical demands of the 21st
This study highlights that neurophobia is indeed a problem among our students but having identified the problem solutions need to be considered. The students themselves have highlighted the need for increased clinical exposure and this must be considered. The Medical School in Mona, Jamaica has introduced bedside teaching from year one and it would be interesting to compare attitudes to neurology among those students as compared to ours. In addition given the general feeling that basic neuroscience is difficult, it is easy to suggest that more time be allocated to the subject. However, this is not readily achievable and is also the desire of almost all other disciplines. The solution perhaps lies in identifying topic areas that have most relevance to doctors in training and streamlining the curriculum; efforts along these lines are in fact in train across the faculty. Along these lines there is also a push to increase vertical integration throughout the curriculum which would increase clinical exposure in the early years of training and also allow the revisiting of basic science concepts during the clinical years.
One obvious limitation of this study was the response rate of 65%. During the clinical years our students function in small group clerkships and rarely come together as a whole group. Given this limitation we distributed the questionnaires within the clerkships and allowed the students to complete them off site. Greater efforts could have been made to follow up with individual students to ensure a higher response rate but this was limited by manpower and the students being spread across four hospitals in different parts of the country. This meant that only the more motivated and perhaps more conscientious students returned the questionnaires, hence the response rate of sixty five percent. However it is to be expected that this population would probably also have been more focused in their attempts to 'come to grips' with neurology and so an increased response rate may have been expected to further highlight the problem of neurophobia.