Toward a more efficient and effective neurologic examination for the 21st century.

Practice pressures and quality improvement require greater efficiency and effectiveness in the neurologic examination. I hypothesized that certain 'marginal' elements of the examination rarely add value and that 'core' elements, exemplified by the plantar response (Babinski), are too often poorly performed or interpreted. I analyzed 100 published, neurologic clinicopathologic conferences (CPCs) and 180 ambulatory neurologic consultations regarding 13 hypothetically 'marginal' examination components (including 'frontal' reflexes, olfaction, jaw strength, corneal reflex, etc.); also, 120 exams on medical inpatients with neurologic problems, recording definitive errors. I surveyed the recalled practices of 24 non-neurologists and reviewed the literature for relevant data or guidance. In the CPCs the 'marginal' elements of the examination were rarely provided, requested, or used diagnostically, nor did they contribute in the 180 ambulatory consultations. In the chart review errors and omissions dominated testing of plantar responses, with missed Babinski signs in 14% of all cases and 77% of patients with Babinski signs. House officers harbored unrealistic expectations for performance of 'marginal' examination elements. Most textbooks omit detailed guidance (and none cite evidence) on achieving greater efficiency. Exams should be streamlined, while improving 'core' skills. Neurologists should apply evidence to update the exam taught to students and non-neurologists.