Single-centre survey links low confidence to neurological exam avoidance

Medical residents surveyed at one centre reported low confidence in key reasoning components of neurological assessment, and their ratings suggested that low confidence was a major reason for skipping parts of a neurological examination. The study, involving 97 internal medicine and family medicine residents, found that residents were least confident in localizing neurological problems and forming differential diagnoses. Researchers asked residents to rate their confidence in conducting different aspects of a neurological evaluation through a self-administered survey.

Low confidence was defined as a score of 3 or lower on a five-point Likert scale. Among the 97 respondents were 35 internal medicine residents and 61 family medicine residents: 36 first-year, 45 second-year and 14 third-year residents. Confidence was lowest for localization, with a median score of 3 and an interquartile range of 2–4.

Confidence in forming a differential was also lower than elsewhere in the assessment, with a median of 4 and an interquartile range of 3–4. Confidence did not increase with additional years of postgraduate training. Residents instead reported that greater exposure to neurology and additional teaching would improve their confidence.

The survey also did not directly test whether low confidence caused residents to omit neurological examinations or established any effect on patient outcomes. Residents rated their peers as most likely to skip neurological and musculoskeletal examinations. For neurological examinations, the median perceived likelihood of skipping was 3 on the five-point scale, with an interquartile range of 2–3; for musculoskeletal examinations, the median was also 3, with an interquartile range of 2–4.

The reported likelihood of skipping part of a neurological examination increased from postgraduate year one to year two. In free-text responses, residents cited low confidence and lack of time as major contributors to examination avoidance. The findings offer a limited snapshot because the study was conducted at a single centre, only 97 of 350 eligible residents responded, and both confidence and perceived peer behavior were measured by self-report rather than direct observation.

The results therefore cannot establish actual rates of neurological examination omission in clinical practice. Within those constraints, the survey identified low confidence in localization and differential diagnosis as prominent concerns and reported lack of time as an additional practical barrier.

Subject of Research: Neurological examination confidence and exam avoidance among medical residents

Article Title: Confidence in the neurological examination and exam avoidance among medical residents

Article References: Keeling, A. B., & Daniels, V. J. (2026). Confidence in the neurological examination and exam avoidance among medical residents. PLOS One, 21(10), e0360249. https://doi.org/10.1371/journal.pone.0360249

Image Credits: AI Generated

DOI: 10.1371/journal.pone.0360249

Keywords: medical residents, neurological examination, clinical confidence, exam avoidance, localization, differential diagnosis, medical education, neurology training, Confidence, neurological, examination, exam