AMERICANBOARDOFPSYCHIATRYANDNEUROLOGY

CLINICALSKILLSEVALUATIONOFRESIDENTSIN
NEUROLOGYANDCHILDNEUROLOGY
July2006

GeneralPrinciples

TheAmericanBoardofPsychiatryandNeurology(ABPN)mandatesthat
demonstrationofclinicalskillscompetencyisabasicrequirementinorderto
applyforcertificationinthespecialtiesofneurologyandneurologywithspecial
qualificationinchildneurology.Competencyintheseskillsshouldbeachieved
duringresidency.TheABPNrequiresthatresidentsdemonstratecompetencyin
thefollowingareas:

A. Medicalinterviewing
B. Neurologicalexamination
C. Humanisticqualities,professionalism,andcounselingskills

Demonstrationofcompetencyinevaluatingaminimumoffivedifferentpatients
(asspecifiedbelow)duringresidencytrainingisrequired.Anindividual
trainingprogrammayelecttodomoresuchevaluations.

RequiredClinicalSkillsEvaluations

AdultNeurologyResidents

1)
Criticalcare:Onecriticallyilladultpatientwithneurologicaldisease
(maybeineitheranintensivecareunitoremergencydepartment
settingoranemergencyconsultationfromanotherinpatientservice)
2)
Neuromuscular:Oneadultpatientwithaneuromusculardisease
(maybeineitheraninpatientoroutpatientsetting)
3)
Ambulatory:Oneadultpatientwithanepisodicdisorder,suchas
seizuresormigraine(mostlikelyinanoutpatientsetting)
4)
Neurodegenerative:Oneadultpatientwithaneurodegenerative
disorder,suchasdementia,amovementdisorder,ormultiplesclerosis
(mostlikelyinanoutpatientsetting)
5)
Childpatient:Onechildpatientwithaneurologicaldisorder(most
likelyinanoutpatientsetting)

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ChildNeurologyResidents

1)
Criticalcare:Onecriticallyillchildpatientwithneurologicaldisease
(maybeineitheranintensivecareunitoremergencydepartment
settingoranemergencyconsultationfromanotherinpatientservice)
2)
Neuromuscular:Onechildpatientwithaneuromusculardisease(may
beineitheraninpatientoroutpatientsetting)
3)
Ambulatory:Onechildpatientwithanepisodicdisorder,suchas
seizuresormigraine(mostlikelyinanoutpatientsetting)
4)
Neurodegenerative:Onechildpatientwithaneurodegenerative
disorder,suchasaninheriteddegenerativedisease(mostlikelyinan
outpatientsetting)
5)
Adultpatient:Oneadultpatientwithaneurologicaldisorder(most
likelyinanoutpatientsetting)

Atleastoneoftheabovechildpatientsmustbe:
Aninfantorchildagedyoungerthantwo
Achildagedsixtoten
Anadolescent(aged1115)

Theselectionofpatients(outlinedabove)bytypeandageisatthediscretionof
theresidencydirector.

SelectionofPatients

Ifpossible,thepatientsshouldbeunknowntotheresident.Whileitispreferable
thatthepatientshavenotbeenseenpreviouslybyanyresident,patients
previouslyseenattheinstitutionmaybeaskedtoparticipateintheevaluation
process.Wheneverpossible,patientswithconversiondisordersorsomatoform
disordersshouldnotbeselected.Theselectionofpatientsisatthediscretionof
theresidencydirector.

Evaluators

EachresidentmustbeevaluatedbyaminimumofthreeABPNcertified
neurologists/childneurologistswhoarefacultymembers.Adultneurologists
mustperformtheadultneurologyevaluations,andchildneurologistsmust
performthechildneurologyevaluations.Thefacultymembermustobservethe
residentsperformanceandscoretheresidentsmedicalinterviewingskills;
neurologicalexaminationskills;humanisticqualities,professionalism,and
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counselingskills.Theresidentsabilitytopresentandformulatethecaseshould
alsobeevaluated,butthatassessmentisnottobefactoredintotheoverall
evaluation.

DurationofEachEncounter

Eachevaluationsessionshouldlastapproximatelyonehour.Theresidents
shouldbegivenupto45minutestodothehistoryandneurologicalexamination.
Thereafter,he/sheshouldhave1015minutestopresentasummaryofthe
importantfindingsonhistoryandneurologicalexamination.Theremainderof
thetimeshouldbespentindiscussionandfeedbackfromthefacultymember
whoobservedtheencounter.

Whilethefacultymembermaywishtodiscussthediagnosis,differential
diagnosis,andplansforevaluationandtreatmentwiththeresident,thesesteps
arenotrequiredbytheABPN.Theresidentdoesnotneedtodemonstrate
proficiencyintheseaspectsoftheencountertopasstheclinicalskillsevaluation.
ThesecompetencieswillbetestedbytheABPNonthecertificationexamination.

TimingoftheEvaluations

TheABPNencouragesadministeringtheseevaluationsearlyinresidency
training.TheABPNanticipatesthatmanyresidentsmaynotpassalltheir
evaluationsonthefirstattempt.Earlyevaluationprovidesanopportunityfor
theresidentstorectifyanydeficienciesandtosuccessfullycompletetheprocess
inordertoapplytotakethecertificationexamination.

EvaluationFormsandScoringCriteria

ApprovedevaluationformsarepostedontheABPNwebsite
(http://www.abpn.com/forms.htm).Twoformsarecurrentlyavailable(NEXv.1
andNEXv.2).Programscanaddadditionalitemsfortheirownpurposes.
Criteriaforscoringthecomponentsoftheclinicalskillsevaluationareprovided
below.

DeterminationofPassingtheEvaluation

Theindividualfacultymemberwilldetermineiftheresidentpassedallthree
corecomponents(A.medicalinterviewing,B.neurologicalexamination,and

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C.humanisticqualities,professionalism,andcounselingskills)oftheclinical
evaluation.

Apassingscoreisrequiredforallthreecomponents(A,B,andC)foranoverall
passingscore.Regardlessofwhenduringtrainingtheresidenttakesthe
evaluation,thestandardforpassingremainsthesame.

Becausetheresidentmaytakeeachoftheseclinicalskillsevaluationsmultiple
timesifnecessary(whichwillnotaffecttheresidentseligibilityfortakingthe
ABPNcertificationexamination),thereshouldnotbepressuretopassa
residentsperformanceonanevaluation.Iftheperformanceislessthandesired,
theresidentandfacultycanscheduleotherencountersandusetheseexperiences
asteachingexercises.

SubmissionofDocumentationtotheABPN

TheABPNrequireswrittenattestationfromthetrainingdirectorthattheresident
hassuccessfullypassedallfiveclinicalskillsevaluationsatthetimeof
applicationforcertification.Thenumberoftimesthattheresidenttakesoneof
theclinicalskillsevaluationsisnotrequired.Itisrecommendedthattheprogram
retaintheevaluationformsaspartoftheresidentstrainingfile.

ComponentsoftheClinicalSkillsEvaluationandScoringCriteria

A. MedicalInterviewingSkills

Theabilitytoobtainaclearhistoryisafundamentalcomponentofthecore
competencyofpatientcare.Theartofbeinganexcellentneurologististhe
abilitytomakeanaccuratelocalizationofthepatientsneurologicalillnessandto
reachamostlikelydiagnosisbasedonthepatientshistory.TheABPNexpects
thatresidentshaveachievedcompetencyinthisskillpriortobeingpermittedto
takethecertificationexamination.Thefacultymembershouldobservethe
residentsskillsandthoroughnessinobtainingthehistory.

TheABPNrecognizesthatneurologistsmayuseseveraldifferentstrategiesto
obtainthehistoryfromapatientandthattheapproachmayvaryamong
differentpatients.Thus,theABPNrequiresthatresidentssuccessfully
demonstratetheabilitytoperformathoroughandaccuratehistoryina
minimumoffiveencounters.

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Theresidentisexpectedtoaskaboutthechiefcomplaint,thehistoryofthe
presentillness,pastmedicalhistory,familyhistory,socialhistory,andareview
ofsystems.Thequalityandcompletenessoftheinformationcollectedfromall
componentsofthehistoryshouldbeevaluated.TheABPNexpectstheresident
toskillfullyobtainthehistory.Whiletheemphasisofthehistoryshouldrelateto
thepatientsneurologicalillness,relevantcomponentsoftheotheraspectsof
historyshouldbementioned.Forexample,ifthepatienthashadastroke,itis
relevanttoaskabouthypertension,heartdisease,afamilyhistoryofstroke,
smoking,andrecentcardiaccomplaints.

Dependinguponthepatient,theresidentcanuseverydirectoropenended
questions.Thetechniqueusedbytheresidenttoobtainthehistorical
informationreflectstheresidentsabilitytocommunicatewiththepatientaswell
ashis/herabilitytochangetechniquestoobtainthenecessaryinformation.

Theresidentshouldnotreviewpriormedicalrecordsinordertoobtainthe
patientshistory.Thefocusofthisevaluationisontheabilityoftheresidentto
obtainthehistoryfromanewpatientorfamilymembers/observers,aswould
bedoneinpractice.

Theresidentisexpectedtoobtaininformationaboutthedurationandcourseof
theneurologicalillnessandthetypesofneurologicalsymptoms.Whilea
chronologicalapproachoftenisdesirable,differentstrategiesareacceptable.If
appropriate,theresidentshouldobtaininformationaboutanyincidentorevent
thatmayhaveprecipitatedtheneurologicalproblems.Ifitisalongstanding
illness,theresidentshouldaskaboutrecentchanges.Ifitisanepisodicdisorder,
informationaboutthenumberandtypesofevents,provocations,durationof
symptoms,etc.shouldbeobtained.Theresidentshouldaskquestionsthatprobe
forbothpositive(presenceof)ornegative(absenceof)importantsymptomsor
componentsoftheneurologicalhistory.Theseincludepain,lossof
consciousness,weakness,etc.Informationaboutpriortreatment(medications,
surgery,etc.)canprovideimportantdiagnosticclues.Didtheresidentmiss
importanthistoricalcluesofferedbythepatient?Didtheresidentfollowupon
componentsofthehistory?

Attheendofthehistory,boththeresidentandtheobservingfacultymember
shouldhaveaclearunderstandingofthenatureofthepatientsneurological
illness.

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Score
8(Outstanding)

ScoringCriteriaforMedicalInterview
Thehistorywasperformedwithoutcriticism.Thehistory
providesaclearunderstandingofthepatientsneurological
illness.
7(Excellent)
Afewminordeficienciesorerrorsinthehistory
6(Verygood)
Minordeficienciesorerrorsinthehistory
5(Acceptable)
Deficienciesorerrorsinhistorybutenoughinformationis
obtainedtoformulatethecase
4(Borderlinebut Haddeficienciesorerrorsinobtainingthehistorywhich
unacceptable)
resultedinmissinginformation
3
Majordeficienciesorerrorsinobtainingthehistoryresulting
(Unsatisfactory) inmissingimportantinformation.Performancebelowother
residentsatsameleveloftraining.
2(Poor)
Omittedmajorportionsofthehistory,resultingininadequate
understandingofthecase.Performancebelowexpectations
forleveloftraining.
1(Verypoor)
Historywassopoorlydonethattheresidentcouldnot
understandthecase.Performancefarbelowexpectationsfor
leveloftraining.

Ascoreof5orgreaterisrequiredtopassthiscomponentoftheclinicalskills
evaluation.

B. NeurologicalExaminationSkills

Theabilitytoperformathoroughexaminationisamajorcomponentofthecore
competencyofpatientcare.Foraneurologist,theabilitytodoaneurological
examinationisafundamentalclinicalskill.

TheABPNrecognizesthattherearedifferentapproachestotheneurological
examinationandnoparticularstyle,sequence,ororganizationisrequired.
However,theABPNexpectstheneurologicalexaminationtobethoroughandto
assessmentalstatus,stationandgait,motor,sensory,coordination(cerebellar),
cranialnerves,andreflexes.Insomecircumstances,suchasawheelchairbound
patient,partsoftheexaminationmaybeomitted.WhiletheABPNexpectsthat
allaspectsoftheexaminationwillbeperformed,componentsoftheexamination
shouldreflectthenatureofthepatientsproblem(asobtainedfromthehistory).
Someadjustmentsshouldbeexpected.Forexample,theresidentmaywishtodo
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amoredetailedmentalstatusexaminationinapatientwithachiefcomplaintof
memorylossthaninapatientwithsymptomsofatardyulnarpalsy.

Theresidentshouldnotbeexpectedtodoageneralphysicalexamination.In
somecircumstances,componentsofthegeneralexaminationmayberelevantto
thepatientspresentation.Forexample,theresidentmaywishtoauscultatefor
bruitsinapatientwithaTIA.

Theresidentsinteractionswiththepatientduringtheexaminationshouldbe
assessed.Wastheresidentrough?Forexample,didtheresidentexaminea
painfullegtotheobviousdiscomfortofthepatient,despitebeingwarnednotto
doso?Didtheresidentdocomponentsoftheexaminationinthecorrect
manner?Didtheresidentusetheappropriateinstrumentsandwerethe
instrumentsusedcorrectly?Weremajorrelevantportionsoftheexamination
missed?Didtheresidentdetecttherelevantneurologicalsigns?Didthe
residentignoreormisinterpretsomeoftheneurologicalfindings?Didthe
residentadjusttheexaminationinresponsetopreviouslydetectedsigns?Did
thefindingsoftheexaminationprompttheresidenttoaskadditionalhistory?
Didthefindingsoftheexaminationpromptreconsiderationofthelocationor
natureoftheneurologicalillness?

Attheendoftheexamination,boththeresidentandthefacultymembershould
haveaclearunderstandingofthelocationandnatureofthepatients
neurologicalillness.Thefindingsontheexaminationshouldbecompatiblewith
thepatientsneurologicalhistory.

Score
ScoringCriteriaforNeurologicalExamination
8(Outstanding) Theneurologicalexaminationwasperformedwithno
detectedshortcomings
7(Excellent)
Afewminordeficienciesorerrorsintheneurological
examination
6(Verygood)
Minordeficienciesorerrorsintheneurologicalexamination
5(Acceptable)
Deficienciesorerrorsintheneurologicalexaminationbut
obtainedenoughinformationtoformulatethecase
4(Borderlinebut Haddeficienciesorerrorsinperformingtheexamination
unacceptable)
resultinginmissinginformation
3
Majordeficienciesorerrorsinperformingtheexamination
(Unsatisfactory) resultinginmissingimportantinformation.Performance
belowotherresidentsatsameleveloftraining.

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2(Poor)

1(Verypoor)

Omittedmajorportionsoftheexaminationresultingin
inadequateunderstandingofthecase.Performancebelow
expectationsforleveloftraining.
Examinationwassopoorlydonethattheresidentdidnot
understandthecase.Performancefarbelowexpectationsfor
leveloftraining.

Ascoreof5orgreaterisrequiredtopassthiscomponentoftheclinicalskills
evaluation.

C. HumanisticQualities,Professionalism,andCounselingSkills

Theabilitytocommunicateeffectivelywithpatientsandfamiliesisoneofthesix
corecompetenciesforphysicians.Effectivecommunicationisakeycomponent
ofaphysiciansinterpersonalskillsandinthedevelopmentofanappropriate
patientdoctorrelationship.Inordertodetermineifresidentsareableto
communicateclearlyandthoroughlywithpatientsinanumberofclinical
settings,includingcriticallyillpatients,theABPNisrequiringevidencethatthe
residenthaspassedthiscorecompetency.

Thecommunicationskillsoftheresidentshouldbeassessedthroughoutthe
patientencounter.Thecommunicationcanincludebothverbalandnonverbal
means.Forexample,beingroughduringtheexaminationcanconveyalackof
skillincommunication.Theresidentsperformanceshouldbescoredinlightof
thepatientsabilitytocooperatewiththeexamination.Whilethereisnoset
criterionforpassingthiscompetency,theoverallperformanceshouldbethe
basisforgradingthisclinicalskill.

Theresidentshouldbesensitivetoethnic,racial,religious,orculturalissues.
Theresidentalsoshouldbeawareofeducational,language,orcommunityissues
thatmayaffectthepatientsabilitytocommunicate.Theresidentshouldtake
stepsoremploystrategiesthatdealwiththeseissuesandatthesametimepermit
anaccuratehistoryandexamination.IfthepatientdoesnotspeakEnglish,the
residentshouldseekotherwaystocommunicatewiththepatient,suchastheuse
ofatranslatorortalkingtofamilymemberswhoareproficientinEnglish.

Thedialoguebetweenthepatientandtheresidentshouldbeevaluated.Didthe
residentmakethepatientandfamilyfeelascomfortableaspossibleinthe
situation?Didtheresidentinteractinaneutralorpositivewaywiththepatient?

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Didtheresidentdemonstraterespectforthepatientandfamily?Wasthe
residentrude,brusqueordemanding?Didtheresidentinterruptthepatient
duringthehistory?Didtheresidentfailtofollowuponthepatientscomments?
Didtheresidentallowthepatienttorespondtoquestions?Didtheresident
reviseorreformatquestionswhenitappearedthatthepatientdidnot
understand?Didtheresidentdirectquestionstofamilymembersifitappeared
thatthepatientdidnothaveinformationaboutpartofthehistory?Didthe
residentexplainthecomponentsoftheneurologicalexaminationandgiveclear
instructions?

Score
ScoringCriteriaforHumanisticQualities,Professionalism,
andCounselingSkills
8(Outstanding) Effectivecommunicationskillsandpatientdoctor
interactions
7(Excellent)
Afewminorproblemsincommunicationorpatientdoctor
interactions
6(Verygood)
Minorproblemsincommunicationorpatientdoctor
interactions
5(Acceptable)
Hadproblemsincommunicationorpatientdoctor
interactionsbutstillestablishedrapport
4(Borderlinebut Hadproblemsincommunicationorpatientdoctor
unacceptable)
interactions,rapportwithpatientwasborderlineornotgood
3
Majorproblemsincommunicationorpatientdoctor
(Unsatisfactory) interactions,unabletoestablishrapportwithpatient
2(Poor)
Majorproblemswithcommunication,rudeorunpleasantto
patient
1(Verypoor)
Interactionsorcommunicationwiththepatientweresobad
thatthefacultymemberneededtointervene

Ascoreof5orgreaterisrequiredtopassthiscomponentoftheclinicalskills
evaluation.

D. OverallEvaluation

Theindividualfacultymemberwilldetermineiftheresidentpassedallthree
corecomponents(A.medicalinterviewing,B.neurologicalexamination,and
C.humanisticqualities,professionalism,andcounselingskills)oftheclinical
evaluation.

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Apassingscoreisrequiredforallthreecomponents(A.,B.,andC.)foranoverall
passingscore.Regardlessofwhenduringtrainingtheresidenttakesthe
evaluation,thestandardforpassingremainsthesame.

E. Presentation/Formulation

Theresidentsabilitytopresentandformulatethecaseshouldalsobeevaluated,
butthatassessmentshouldnotbefactoredintotheoverallevaluation.

Score
ScoringCriteriaforPresentation/Formulation
8(Outstanding) Nomajordeficienciesinthedescriptionofthekeyfindingsof
thehistoryandneurologicalexamination
7(Excellent)
Oneminordeficiencyinthedescriptionofthekeyfindingsof
thehistoryorneurologicalexamination
6(Verygood)
Twominordeficienciesinthedescriptionofthekeyfindings
ofthehistoryorneurologicalexamination
5(Acceptable)
Afewminordeficienciesoronemajordeficiencyinthe
descriptionofthekeyfindingsofthehistoryorneurological
examination
4(Borderlinebut Severalminordeficienciesortwomajordeficienciesinthe
unacceptable)
descriptionofthekeyfindingsofthehistoryorneurological
examination;missedsomepoints
3
Severalmajordeficienciesinthedescriptionofthekey
(Unsatisfactory) findingsofthehistoryorneurologicalexamination;missed
severalpoints
2(Poor)
Multiplemajordeficienciesinthedescriptionofthekey
findingsofthehistoryorneurologicalexamination;summary
offindingswasincomprehensible
1(Verypoor)
Numerousmajordeficienciesinthedescriptionofthekey

findingsofthehistoryorneurologicalexamination;summary

offindingswasincomprehensible

Ascoreof5orgreaterisrequiredtopassthiscomponentoftheclinicalskills
evaluation,thoughitisnotrequiredfortheoverallevaluation.

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