Is it time to reconsider the classic neurological examination?

When I was a resident almost 40 years ago, my attending physician, Dr Jerome Posner, confided in me that he thought it takes 20 years to make a neurologist. In my third year of training at the time, I was disheartened to hear how far away I was from this goal, but a little arithmetic convinced me that at the time, Dr Posner was about 20 years out of his own residency, and he probably meant that one continues to learn in neurology and to refine one’s examination and diagnostic capabilities throughout one’s career. One of the main things that neurologists learn, especially in these days when we may spend parts of our careers at several different institutions, is that there is no one true way to do the neurological examination. There are many variations in parts of the examination from place to place, and of course experienced neurologists often deviate from the Classic Neurological Examination to focus on what is bothering a specific patient. Pediatric neurologists probably smile at that, because they have known all along that interacting with the patient in the sphere of his or her problem is the best way to figure out what is going on. But adult neurologists have carried the burden of Classic Neurological Examination, which has been handed down from generation to generation. This examination today is similar to the one that was codified by Gordon Holmes at Queen Square in the early 20th century, and which was carried to the United States by his disciple, Derek Denny-Brown. Denny-Brown produced a small booklet called the Handbook of Neurological Examination and Case Recording, which outlined the history and examination that was expected of residents in the Boston City Hospital Neurology Program that he led. That program moved to Beth Israel Hospital in 1975, and we still hand out an updated version of that book to medical students and residents in our training program. Similar booklets and examinations are taught across the United States and in most of the world today. The examination that is almost universally used now will be familiar to almost all readers of these words. It is based on a segmental approach, including a cognitive (mental status, higher intellectual functions) examination meant to test cortical cognitive functions; a cranial nerve examination, to test brainstem functions; then sensory and motor examinations, which test these functions in each dermatome and myotome; and finally, a coordination (cerebellar) examination, testing sensorimotor integration. Muscle stretch reflexes (also erroneously called deep tendon reflexes) are included, usually with a stick figure or in a table. Denny-Brown liked maps of sensory loss, and under his successor Norman Geschwind, a cognitive neurologist, few patients passed through our neurology service without benefit of drawing a clock. Both map and clock were dutifully included in the patients’ paper charts, but in the modern era of electronic notes, these aspects of the examination are usually described in words. Although the value of that examination should be apparent to all, most experienced neurologists will also recognize its limitations. A completely thorough neurological examination would take hours, and so the examination that is done at the bedside is usually focused by the neurologist based on the patient’s history. The history, which is really a bioassay of the function of the patient in their own environment, is used to make a hypothesis about the nature of the problem. The examination is then focused on exploring that problem and either confirming or falsifying the hypothesis. Some parts of the examination may be expanded in one patient (eg, cognitive testing in a patient who has problems with visuospatial integration), but minimized in the next (eg, a young person with sciatica), in whom other parts of the examination (detailed muscle testing) may be emphasized. Unfortunately, these subtleties are now being lost due to the unfortunate insistence of the Centers for Medicare and Medicaid (CMMS) on paying for medical care