How Well Do Neurology Residents Recognize Multiple Sclerosis? Analysis of the Close the Loop Resident Clinical Acumen Assessment Project

Background: Morning report is a universal component of neurology resident education and a crucial venue where future neurologists' clinical acumen is refined.

Objectives: To characterize cases of demyelinating disease/multiple sclerosis (MS) seen by on-call neurology residents and to assess accuracy of their initial diagnostic impressions, identifying individual and systemic educational needs to improve MS diagnosis.

Methods: For 3 academic years (July 2010 to June 2013) all patients independently assessed and presented by on-call junior residents during our daily morning report were databased. We recorded the residents' initial diagnostic impression and "closed the loop" by revisiting each case after reviewing the final diagnosis. We categorized cases as having a final diagnosis of a primary neurological condition or as "non-neurological" (medical, psychiatric, ophthalmologic, other). Neurological cases were cataloged by etiology, including demyelinating disease/MS. We compared residents' initial diagnostic impression to the final diagnosis to assess whether the initial impression was accurate or inaccurate.

Results: 834 cases were presented in total and 31 (3.7%) had a final diagnosis of demyelinating disease/MS. Overall resident diagnostic accuracy was 70.9%, with accuracy of 74.2% for demyelinating disease/MS. Residents' highest accuracy was in ischemic stroke (82.3%) and seizure (75.6%), which were the most frequent diagnoses presented (n = 121 and 59, respectively). MS-related errors were analyzed: there were 8 cases of demyelinating disease/MS that were initially missed, including those mistakenly diagnosed as CNS infection, medical illness, trauma, and neoplasm. Conversely, there were 13 cases erroneously initially diagnosed as demyelinating disease, which were ultimately determined to have other conditions including medical illness, neoplasm, neuropathy, and psychiatric illness. 

Conclusions: This project presents a novel educational initiative to assess and improve neurology resident clinical acumen. Diagnostic accuracy for identifying MS/demyelinating disorders was less than the accuracy of the most frequent diagnoses seen by residents (ischemic stroke and seizure), likely due to the smaller number of cases presented in this category. It is essential for future neurologists to be highly proficient in diagnosis MS.  By analyzing the specific types of errors made, we can refine educational strategies to enhance residents’ MS-related diagnostic skills.