Nerve Conduction Studies & Evoked Potentials 2 —
Training activity: 8

Details

Interpret results of evoked potential studies and make recommendations for further investigations/tests in line with clinical context of patient’s history and symptoms

Type

Entrustable training activity (ETA)

Evidence requirements

Evidence the activity has been undertaken by the trainee repeatedly, consistently, and effectively over time, in a range of situations. This may include occasions where the trainee has not successfully achieved the outcome of the activity themselves. For example, because it was not appropriate to undertake the task in the circumstances or the trainees recognised their own limitations and sought help or advice to ensure the activity reached an appropriate conclusion. ​

Reflection at multiple timepoints on the trainee learning journey for this activity.

Reflective practice guidance

The guidance below is provided to support reflection at different time points, providing you with questions to aid you to reflect for this training activity. They are provided for guidance and should not be considered as a mandatory checklist. Trainees should not be expected to provide answers to each of the guidance questions listed.

Before action

What does success look like?

• Identify what is expected of you in relation to interpreting evoked potential study results (e.g., visual, auditory, somatosensory, motor, cognitive) and making recommendations for further investigations/tests based on the patient’s clinical history and symptoms.
• Consider how the learning outcomes apply, specifically in relation to identifying further investigations, interpreting evoked potential studies, and demonstrating effective communication.
• Discuss with your training officer to gain clarity of what is expected of you in relation to successful interpretation of different evoked potential modalities and appropriate recommendations in various clinical contexts.

What is your prior experience of this activity?

• Think about what you already know about evoked potential studies, their physiological basis, and interpretation.
• Consider possible challenges you might face during the activity, such as interpreting complex waveforms (e.g., cognitive EP), correlating findings with diverse neurological conditions (e.g., demyelination, stroke, trauma), or determining the most appropriate follow-up investigations based on history and symptoms, and think about how you might handle them.
• Recognise the scope of your own practice for this activity i.e. know when you will need to seek advice or help, and from whom. You will need to seek advice from your Training Officer when required, for example:
  • If the interpretation suggests a central demyelinating disease requiring immediate referral pathway clarification
  • When assessing the prognostic value of an EP in a critically ill patient where findings are complex
  • If ancillary techniques (e.g., specialised cognitive EP) are required for follow-up and are outside routine practice
• Acknowledge how you feel about interpreting the results and making recommendations for further tests in the context of this training activity.

What do you anticipate you will learn from the experience?

• Consider the specific skills you want to develop, such as systematically analysing different evoked potential waveforms, applying knowledge of their pathophysiology and clinical uses, correlating findings with patient presentation, and formulating evidence-based recommendations, drawing upon previous experiences.
• Identify the specific insights you hope to gain into understanding the diagnostic value and limitations of various evoked potential modalities or appreciating how interpretation contributes to the diagnosis and management of central and peripheral neurological conditions.

What additional considerations do you need to make?

• Consult actions identified following previous experiences of interpreting evoked potentials or related neurological investigations.
• Identify important information you need to consider before embarking on the activity, such as the technical aspects of the study performed, the specific clinical question being addressed, the patient’s detailed history and symptoms, and guidelines for further neurological investigations.

In action

Is anything unexpected occurring?

• Are you noticing anything surprising or different from what you anticipate whilst interpreting the evoked potential (EP) study results and formulating recommendations?
• Are you encountering situations such as:
  • The Somatosensory Evoked Potential (SSEP) results show abnormalities suggesting central demyelination, but the initial clinical history was vague or non-specific?
  • The Motor Evoked Potential (MEP) findings in a stroke patient show complex prognostic values that are difficult to translate into clear recommendations for further recovery assessment?
  • You are presented with cognitive EP results that are highly ambiguous or conflicting, challenging your diagnostic conclusion?

How are you reacting to the unexpected development?

• How is this impacting your actions? For example, are you responding to the situation appropriately? Are you adapting or changing your approach to integrating multimodality EP findings with the patient’s history?
• Consider the steps you are taking in the moment, such as:
  • Immediately reviewing the technical quality of the specific EP modality (VEP, AEP, SSEP) before proceeding with interpretation
  • Formulating recommendations that specifically request further testing (e.g., MRI for central demyelination) that falls outside the immediate scope of neurophysiology
• How are you feeling in that moment? For instance, are you finding it difficult to apply complex theory to practical interpretation? Is it affecting your confidence in identifying appropriate follow-up investigations?

What is the conclusion or outcome?

• Identify how you are working within your scope of practice. For example, are you successfully identifying a clear pathology (e.g., optic nerve delay in VEP) and recommending standard follow-up? Or are you needing support because the findings are highly complex or conflicting (e.g., ambiguous prognostic value in critical care) requiring specialist clinical review before finalising the recommendations?
• What are you learning as a result of the unexpected development? For example, are you mastering a more effective systematic approach to interpreting multimodality EP results? Or gaining insight into the diverse clinical applications and prognostic value of various EP studies?

On action

What happened?

• Begin by summarising the key steps you took when interpreting evoked potential (EP) study results and formulating recommendations. Which modalities did you interpret (e.g., visual, auditory, somatosensory, motor, cognitive)?
• Consider specific events, actions, or interactions which felt important, such as how you analysed the latency and morphology of the VEP P100 component, or how you correlated multiple EP findings (e.g., abnormal SSEP and normal MEP) to localise a central lesion.
• Include any ‘reflect-in-action’ moments where you had to adapt to the situation as it unfolded, for instance, re-evaluating the possibility of central demyelination when the SSEP showed unexpectedly prolonged central conduction time, leading to a recommendation for MRI.
• How did you feel during this experience, e.g., were you confident in integrating complex findings from different modalities, or challenged by the need to assess the prognostic value of the findings?

How has this experience contributed to your developing practice?

• Identify what learning you can take from this experience regarding EP interpretation and recommendation. What strengths did you demonstrate, e.g., systematic analysis of EP waveform components? What skills and/or knowledge gaps were evident, e.g., unfamiliarity with the interpretation and prognostic applications of complex cognitive EPs or knowing the appropriate non-neurophysiology investigations based on central localisation?
• Compare this experience against previous engagement with similar activities – has your practice improved in correlating physiological data with complex neurological conditions?
• Identify any challenges you experienced, such as needing to seek advice or clarification on scope of practice regarding the interpretation of highly ambiguous or conflicting multimodality EP results, and how you reacted to this.

What will you take from the experience moving forward?

• Identify the actions or ‘next steps’ you will now take to support the assimilation of what you have learnt, including from any feedback you have received, with regards to interpreting EP studies and making recommendations.
• What will you do differently next time you approach EP interpretation, for instance, by proactively reviewing the patient’s imaging status (e.g., MRI) before finalising recommendations to avoid unnecessary duplication?
• Do you need to practise any aspect of the activity further, such as reviewing the pathophysiology reflected by specific EP delays or key learning outcomes related to identifying further investigations?

Beyond action

Have you revisited the experiences?

• How have your subsequent experiences interpreting evoked potential (EP) studies (e.g., SSEP, VEP, AEP, cognitive EPs), since completing this specific training activity led you to revisit your initial approach or decisions during that activity? For example, how an instance where a subsequent complex case required interpretation of cognitive EPs forced you to re-evaluate the breadth of your understanding of central nervous system lesion localisation you applied during your first attempt at EP interpretation.
• Considering what you understand about EP interpretation, prognostic value, and identifying further investigations now, were the actions or considerations you identified after your initial reflection on this training activity sufficient? How have you since implemented or adapted improvements in your EP interpretation methodology and recommendation formulation based on further learning and experiences? For example, how you proactively reviewed and integrated the standardised prognostic criteria for EPs in critical care patients to inform your recommendations, demonstrating you have adapted improvements based on further learning.
• Has discussing ambiguous or conflicting multimodality EP results or the impact of EP interpretation on patient prognosis with colleagues, peers, or supervisors changed how you now view your initial experience in this training activity? For example, how professional storytelling with a senior colleague about a case where SSEP interpretation guided complex decisions regarding central demyelination, refined your understanding of the critical nature of localising lesions accurately.

How have these experiences impacted upon current practice?

• How has the learning from this initial training activity, in combination with subsequent EP interpretation experiences, contributed to your overall confidence and competence in interpreting EPs and identifying further investigations, particularly in preparing for assessments like CBDs? For example, how your accumulated ability in analysing multimodality EP waveforms now enables you to confidently discuss the diagnostic value and limitations of EP studies during a CBD assessment.
• How has reflecting back on this specific training activity, combined with everything you’ve learned since, shaped your current approach to EP interpretation and recommendation? How does this evolved understanding help you identify when something is beyond your scope of practice or requires escalation? For example, how your evolved approach means you now routinely seek advice from the Training Officer or Specialist Neurologist immediately when the interpretation of EPs suggests a complex central degenerative disease requiring non-standard follow-up, recognising this requires specialist input.
• Looking holistically at your training journey, how has this initial EP interpretation experience, revisited with your current perspective, contributed to your development in meeting the learning outcomes related to identifying further investigations and interpretation? For example, how this foundational experience has supported your development in meeting subsequent learning outcomes focused on appraising the evidence base for Intraoperative Monitoring (IOM) which heavily relies on EP principles.

Relevant learning outcomes

#	Outcome
# 6	Outcome Identify further investigations in line with clinical context and the patients history and symptoms.
# 9	Outcome Interpret peripheral nerve conduction studies and evoked potential studies.
# 12	Outcome Demonstrate effective and compassionate communication skills with all stakeholders, including patients and the multidisciplinary team.