Residency Program Curriculum

• 12 two-week blocks of inpatient floor / stroke
• 2 two-week blocks of pediatric neurology (inpatient service)
• 3 two-week blocks of neurocritical care unit
• 1 two-week block of neuroradiology
• 4 two-week blocks at North Shore (Outpatient)
• 2 two-week blocks of elective (4 weeks total)
• 2 two-week blocks of vacation (4 weeks total)

• 2 two-week blocks of pediatric neurology (inpatient service)
• 2 two-week blocks of pediatric neurology (outpatient clinic)
• 3 two-week blocks of neurocritical care unit
• 3 two-week blocks of stroke senior
• 3 two-week blocks of adult consults
• 3 two-week blocks of electroencephalography
• 2 two-week blocks of electromyography
• 4 two-week blocks at North Shore (Consults)
• 2 two-week blocks of elective (4 weeks total)
• 2 two-week blocks of vacation (4 weeks total)

• 5 two-week blocks of adult inpatient floor / stroke (senior)
• 4 two-week blocks of adult outpatient urgent-care clinic
• 4 two-week blocks of neuropathology
• 2 two-week blocks of psychiatry
• 4 two-week blocks at North Shore (elective)
• 5 two-week blocks of elective (10 weeks total)
• 2 two-week blocks of vacation (4 weeks total)

Overview

The adult inpatient neurology ward rotation takes place during the PGY-II year and consists of 12, two-week blocks of inpatient/stroke. The primary focus is on the evaluation and treatment of patients with acute neurological disease many of whom also have concomitant medical problems.

The inpatient floor team consists of one attending, one senior resident (PGY-IV), and four junior residents (PGY-II). One of the PGY-IIs is on night float for six consecutive nights (Sunday through Friday) and the other three PGY-IIs take long call every third night until 8:00pm at which point the night-float person takes over the service. Saturday nights are covered by an ectopic call person (PGY-II or PGY-III). After each new patient encounter, the junior resident (PGY-II) will discuss the case with the senior resident at any time of day or night. The ward senior resident is available 24 hours a day by pager as is the ward attending. All ED send outs must be discussed with the attending.

In the event of an acute stroke code the resident must evaluate the patient within 10 minutes. He/she is expected to have assessed the patient and completed the NIHSS within 30 minutes at which point the resident discusses the patient with the NeuroICU/stroke attending to determine further plans for acute intervention.

Core Competencies

Patient Care

• During this rotation, competence in patient care is developed and demonstrated in the bedside evaluation of patients, in oral case presentations, and in written communications in the patients’ chart.  The supervising attending will evaluate competence in verbal and written presentations.  Clinical skills include the ability to perform a complete history and physical examination, generate a rational differential diagnosis, workup, and management plan, and interpret results of studies in the context of patient care.  Additionally, the resident acquires skills in the acute management of stroke.

Medical Knowledge

• The resident is expected to gradually develop a detailed body of knowledge related to neurological disorders seen on the inpatient neurology service. Medical knowledge is obtained through independent reading of the literature, reading in a disease-specific fashion, and through patient evaluations.  The resident is also expected to apply knowledge from evidence-based medicine to patient care.  Knowledge is also gained through didactic teaching. Senior residents are expected to teach junior residents and medical students. As the year progresses, junior residents will also be expected to participate in medical student teaching.  Teaching skills will be evaluated by the attending physician and by the medical students.

Interpersonal and Communication Skills

• The resident will present patients to the supervising attending succinctly and completely and will maintain comprehensive, timely, and complete medical records. The resident will communicate effectively with patients, families, and other health professionals and will confer with consultants as necessary. The resident will teach basic neurology to the rotating medical students.

Practice-Based Learning and Improvement

• The resident will develop the ability to investigate and evaluate his/her care of patients, to appraise scientific evidence, and to improve patient care based on constant self-evaluation and life-long learning. The supervising attending will ensure that the resident identifies strengths and deficiencies in his/her knowledge and implements changes leading to improvement. The resident will locate and use evidence from scientific studies in his/her care of patients.  The resident will educate patients and their families about the patient’s condition.

Professionalism

• Neurology residents will behave in a professional manner at all times. The highest standards of professionalism must be maintained, especially in interactions with patients or other physicians.  The resident will be responsible for tracking duty hours and entering them in MedHub. The resident should accomplish all assigned tasks related to clinical patient care within the limitations of the ACGME duty hour regulations.  EPIC notes must be completed in a timely fashion.

Systems-Based Practice

• The resident will participate in daily multidisciplinary rounds attended by the social worker, patient care manager, physical and occupational therapists, speech therapist, dieticians, and occasionally representatives of the nursing staff, to discuss current and future needs of patients in addition to post-discharge planning. The resident will be able to complete the necessary workup, coordinate neurological care to the outpatient setting, and will develop appropriate billing skills.

Goals

One of the duties of the Neurology service is to provide excellent care for the patients hospitalized on the inpatient ward. Patients admitted for evaluation and treatment of their neurological problems require care that is comprehensive, cost-effective, and compassionate. The PGY-II resident on the ward service will develop competence at inpatient management for a variety of neurological conditions. The resident must also develop skills at teaching medical students.

1. To provide a concentrated exposure to the presentation, diagnosis, and management of acute neurological illness including acute stroke.
2. To be the first responder to acute stroke codes.
3. To provide exposure to neurological illness in the medical and surgical setting through evaluation of neurological problems that arise on these services at night and on weekends.
4. To become efficient in evaluating, documenting, and managing patients as well as interacting with other hospital systems and staff.
5. All aspects of inpatient care fall under the responsibility of the ward resident in conjunction with the ward senior resident and ward attending.
6. During the night-float week the resident will leave the hospital immediately after presenting his/her admissions during Attending rounds and will not assume responsibilities for new patients until after he/she returns at 8:00pm for the next night-float period.

Educational Objectives

1. Develop skills in independently obtaining a detailed and comprehensive neurological history and physical examination.
2. Develop proficiency in management of acute stroke.
3. Develop a logical approach to localization of neurological lesions, diagnosis of neurological disease, differential diagnosis, and judicious use of diagnostic tests and therapeutic options.
4. Learn the basics of interpretation of MRI and CT scanning of the brain and spinal cord.
5. Learn the basics of utilization of EMG/NCS, and EEG in patient diagnosis and management.
6. Develop effective communication skills with patients (written and verbal), patient’s families, colleagues and co-workers.
7. Develop and maintain a professional manner toward patients, family, peers, and hospital staff.
8. Develop basic teaching skills.

Attending Rounds

Rounds for the night-float resident must end by 10:00am on the post-call day. Rounds will continue on patients of the other three residents and are usually completed before 12:00pm.

The Attending is required to release residents in time to attend all required noon didactic lectures.

Resident Responsibilities

1. During the six consecutive nights of night-float: The resident will be responsible for neurology consultations including acute stroke, admissions, and transfers from 8:00pm to 7:00am the next day.
2. The long-call resident will be responsible for ER consults including acute stoke, admissions and transfers from 1:00pm until 8:00pm and will sign out to the night-float resident at 8:00pm.
3. The admitting resident is responsible for writing the admission orders on all admissions.
4. The junior resident must present the new admissions to the attending on service during morning rounds; the night-float resident is the first to present during rounds and will leave no later than 10:00am after signing out t the team. New inpatient consults seen overnight or on weekends are signed out to the consult resident in the morning.
5. Continuity clinic is cancelled for the night-float junior resident.
6. The junior resident will evaluate patients in the emergency room to assess appropriateness for admission as well as to expedite the evaluation and treatment process.
7. The junior resident will call the senior resident with each new patient evaluation including potential admissions, transfers, and consults. Patient care should be closely coordinated with the ward senior and the attending physician.
8. The junior resident should complete a thorough history and neurological examination for each evaluated patient.
9. Daily progress notes must be written on all patients.
10. All admission notes, progress notes, and discharges summaries MUST BE completed on a timely basis.
11. The junior resident MUST attend stroke morning report on Tuesday and general morning report on Wednesday (the junior resident will present cases at morning report). Attendance at core department lectures is considered mandatory except for the night-float resident. Residents will be asked to sign in at all lectures.

Overview

The PGY-IV resident functions as the ward senior resident for a total of 2.25 months during the final year of neurology training. The PGY-IV’s primary responsibilities include ensuring that patients are receiving quality care, supervision and education of the junior residents and medical students rotating on service, and refining their own knowledge of neurology. The resident is expected to provide intellectual as well as practical back-up to the junior residents. The senior resident should be available to help in performing procedures and ordering tests as well as evaluation of patients when the need arises. The ward attending physician backs up the senior resident.

Patient Care

• While rotating on the inpatient service as ward senior, the PGY-IV resident provides assistance, guidance, support, and supervision to the PGY-II residents on service during the day and at night.  The resident is responsible for overseeing all patient related issues and medical decisions pertaining to patients on service.  The PGY-IV resident is given some degree of autonomy by the supervising attending physician to allow the resident to exercise independent judgment and have a supervisory role.

Medical Knowledge

• The resident will continue to develop and refine his/her knowledge in neuroscience and will teach the junior residents and medical students about various aspects of neurologic disease.

Interpersonal and Communication Skills

• The PGY-IV resident will routinely discuss the patients on service with the junior residents and will provide the junior residents with bedside teaching. The resident will communicate effectively with the attending, patients, families, and other health professionals.

Practice-Based Learning and Improvement

• The resident will continue to develop the ability to investigate and evaluate his/her care of patients, and to improve patient care based on constant self-evaluation and life-long learning. The resident will use evidence from scientific studies in his/her care of patients.  The resident will assist the junior resident in educating patients and their families about the patient’s condition.

Professionalism

• The PGY-IV resident will behave in a professional manner at all times with junior residents and with patients.  The resident will be responsible for tracking and reporting his/her own duty hours and for ensuring that the PGY-II residents are in compliance with duty hour regulations.

Systems-Based Practice

• The PGY-IV resident will teach the junior resident to work as part of a team to enhance patient safety and improve patient care quality.  The PGY-IV resident will teach the junior resident to complete the necessary workup and coordinate neurological care to the outpatient setting. The senior resident is also responsible for tracking any complications that occur in their patients; the data collected will be presented at the quarterly Morbidity and Mortality conference and is expected to lead to quality improvement initiatives.

Goals & Educational Objectives

• To learn to manage larger numbers of patients in an efficient manner both on site and by telephone consultation. This is in preparation for duties as an attending physician post residency.
• To develop leadership and teaching skills and techniques.
• To allow the PGY-IV resident to mature by exercising independent judgment and having a supervisory role in an inpatient setting.
• To continue to acquire knowledge of clinical neurology and the basic neurosciences.

Senior Resident Responsibilities

• Overseeing and organizing the clinical operations on the neurology inpatient service to ensure quality patient care. The senior resident should look through all test results on a daily basis to make sure critical results are followed up on properly.
• Aiding junior residents in decision-making and daily work tasks. The junior resident will call the senior resident with every new patient encounter.
• Conducting and overseeing daily “work rounds” with the junior residents. This will take place at 7:00 or 7:30 am. The senior resident briefly discusses and evaluates all ward patients including their labs, vital signs…
• Providing both leadership and education to junior residents and medical students.
• The senior resident should be available on the ward until at least 5:00 pm on week days and at least to the end of attending rounds on weekends. After hours, the senior resident on service is available by pager.
• The senior resident will come to the hospital during off-hours if deemed necessary and if requested by the junior resident.
• The senior resident should provide intellectual, moral, and practical support to the residents and students that he/she supervises.
• Ensuring that post call night-float resident leaves as soon as possible after appropriate hand-off/sign-out.
• Dealing with hospital transfers. All transfers should be discussed with the Attending prior to acceptance.
• Participate in daily multi-disciplinary rounds and discharge planning attended by physical therapists, occupational therapists, social workers, case workers, and speech therapists, to discuss each patient, their diagnosis, and their relevant needs.

Overview

This brief rotation was developed to provide the incoming PGY-II residents with assistance and guidance while on call at the beginning of each academic year. This rotation takes place in the months of July, August and September. PGY-III and PGY-IV residents function as “in-house seniors or buddies” to assist the junior (PGY-II) resident during night call. The “in-house senior” will be responsible for seeing and managing all new admissions and consults along with the PGY-II resident, from 5:00 pm to 7:00 am the following day. The in-house senior will discuss cases with the ward senior, and if necessary with the ward attending. On average, each PGY-III and PGY-IV resident participates in this rotation for approximately four to five nights per year during the months of July-September.

Core Competencies

Patient Care

• During this brief rotation, competence in patient care is developed and demonstrated in the bedside evaluation of patients. The PGY-III or PGY-IV resident provide assistance, guidance, support, and supervision in patient evaluations, to new PGY-II residents during night call in the first three months of residency.

Medical Knowledge

• The resident will develop a detailed body of knowledge related to neurological disorders seen on the inpatient neurology service.  The PGY-III or IV resident teaches the junior resident how to handle specific clinical situations.

Interpersonal and Communication Skills

• The PGY-III or IV resident will discuss the patient being evaluated with the junior resident and will provide the junior resident with bedside teaching. The resident will communicate effectively with patients, families, and other health professionals.

Practice-Based Learning and Improvement

• The resident will develop the ability to investigate and evaluate his/her care of patients, to appraise scientific evidence, and to improve patient care based on constant self-evaluation and life-long learning. The resident will locate and use evidence from scientific studies in his/her care of patients.  The resident will educate patients and their families about the patient’s condition.

Professionalism

• Neurology residents will behave in a professional manner at all times. The highest standards of professionalism must be maintained, especially in interactions with peers and with patients.  The resident will be responsible for tracking duty hours and reporting them to the Education Administrator and program director. The resident should accomplish all assigned tasks related to clinical patient care within the limitations of the ACGME duty hour regulations.

Systems-Based Practice

• The PGY-III or IV resident will teach the junior resident to work as part of a team to enhance patient safety and improve patient care quality.  The PGY-III or IV resident will teach the junior resident to complete the necessary workup and coordinate neurological care to the outpatient setting.

Goals & Educational Objectives

• To provide assistance, guidance, support, and supervision to our new PGY-II residents during night call in the first three months of residency.
• To help the PGY-II residents in becoming familiar with assessment of patients with urgent neurological problems while on call.
• To ensure that the PGY-II residents are gaining confidence in managing patients with various neurological presentations.
• To assist the PGY-II residents in using the various hospital information systems (EPIC, PACS, etc) while on call.
• To give the more senior residents (PGY-III and PGY-IV) an opportunity to serve as mentors/teachers for the junior residents and to gradually develop independence in managing patients.

Overview

The neurology consultation service rotation takes place during the PGY-II (two weeks) and PGY-III (eight weeks) years. The Consult Service covers all of the adult inpatient units including Medicine, Surgery, medical/surgical ICUs, and OB-GYN, Monday through Friday from 7:00am to 5:00pm. Emergency Room and acute stroke consultations are covered between 7:00am and 1:00pm, at which time the on-call ward resident assumes coverage. The Neurology resident is the first to evaluate patients as requested by the various services. The resident then rounds with the attending on the consultation service at an agreed upon time each day. Patients will be followed up as needed. If outpatient clinic follow up is needed for a particular patient, the patient will be scheduled into the continuity clinic of the consult resident. ER patients seen by the Consult Resident that are to be admitted to the neurology inpatient service should have basic orders, labs and tests completed by the Consult Resident.

In the event of an acute stroke code the resident must evaluate the patient within 10 minutes. He/she is expected to have assessed the patient and completed the NIHSS within 30 minutes at which point the resident discusses the patient with the NeuroICU/stroke attending to determine further plans for acute intervention.

Core Competencies

Residents spend two weeks on the consult service in the PGY-II year and 2 months in the PGY-III year. When a PGY-II resident rotates on the consult service, he/she works with a PGY-III resident.

When a PGY-II and a PGY-III resident rotate simultaneously on the consult service, the PGY-III functions as the “senior” resident and is responsible for overseeing and delegating duties and responsibilities. The PGY-III will assign consults to the PGY-II resident, to the rotating psychiatry PGYI resident or residents from other services (when applicable).

Core competency-based goals for this rotation are as follows:

Patient Care

• During this rotation, competence in patient care is developed and demonstrated in the bedside evaluation of patients, in oral case presentations, and in written communications in the patients’ chart. The PGY-III resident provides assistance, guidance, support, and supervision to the PGY-II resident and other rotating residents when applicable. The supervising attending will evaluate resident competence in verbal and written presentations. Clinical skills include the ability to perform a complete history and physical examination, generate a rational differential diagnosis, formulate workup and management plans, and interpret results of studies in the context of patient care. Additionally, the resident acquires skills in the acute management of stroke.

Medical Knowledge

• The resident is expected to develop a detailed body of knowledge related to neurological disorders that arise in the hospitalized general medical and surgical population. Medical knowledge is obtained through independent reading of the literature, reading in a patient-specific fashion, and through patient evaluations. The resident is also expected to apply knowledge from evidence-based medicine to patient care. Knowledge is also gained through didactic teaching. During this rotation, the PGY-II and PGY-III residents are expected to impart basic knowledge of neurology to rotating residents from other services.

Interpersonal and Communication Skills

• The resident will present patients to the supervising attending succinctly and completely and will maintain comprehensive, timely, and legible medical records. The resident will also communicate findings and recommendations to the requesting service in a clear fashion. The resident will communicate effectively with patients, families, and other health professionals. The resident will work as a member of a multidisciplinary team to maximize the care of complex medically ill patients. The resident will teach basic neurology to the rotating residents from other services.

Practice-Based Learning and Improvement

• The resident will develop the ability to investigate and evaluate his/her care of patients, to appraise scientific evidence, and to improve patient care based on constant self-evaluation and life-long learning. The supervising attending will ensure that the resident identifies strengths and deficiencies in his/her knowledge and implements changes leading to improvement. The resident will locate and use evidence from scientific studies in his/her care of patients. The resident will educate patients and their families about the patient’s condition.

Professionalism

• Neurology residents will behave in a professional manner at all times. The highest standards of professionalism must be maintained, especially in interactions with patients, families, or other physicians. The resident will be responsible for tracking duty hours and logging them in MedHub. The resident should accomplish all assigned tasks related to clinical patient care within the limitations of the ACGME duty hour regulations. EPIC notes must be completed in a timely fashion.  Competence in professionalism will be assessed by supervising attendings.

Systems-Based Practice

• The resident will learn the constraints of acting as a consultant as opposed to being the primary service in providing patient care. The resident will also learn to work as part of a team to enhance patient safety and improve patient care quality. The resident will be able to complete the necessary workup, coordinate neurological care to the outpatient setting, and will develop appropriate billing skills.

Goals & Educational Objectives

• To expose residents to the broad array of acute and chronic neurological disorders that arise in the hospitalized general medical/surgical population.
• To develop competence in the management of acute stroke.
• To learn to interact and communicate effectively with colleagues in other medical disciplines.
• To evaluate patients referred by another clinical service as soon as possible and provide feedback on diagnosis and recommended work-up in a timely fashion.
• To aid in educating other housestaff and medical students with respect to neurological diseases.
• To learn to function as a consultant rather than the primary service.

Responsibilities

• The Consult resident will be responsible for all consults requested by other services and medical/surgical ICUs from 7:00am to 5:00pm and all ER and acute stroke consults between 7:00am and 1:00pm, on weekdays. Between 5:00pm and 7:00am on weekdays and throughout the weekend, the On-Call resident will be responsible for cross covering staffed consults and evaluating new consults.
• The neurology resident (PGY-II or III) will supervise non-neurology resident rotators in their evaluations of patients.
• All consults must be staffed with an attending within a 24-hour period.
• The consult service will round on follow-up patients as necessary.
• The consult team will round daily with the Consult attending at an agreed upon time.

Overview

The Neuro-ICU service cares for critically ill neurological and neurosurgical patients in the Neuro-ICU, as well as neurocritical care consultations in other ICUs. The Neurology Resident is exposed to, and is responsible for, the care of these patients, which will broaden their knowledge and experience via a variety of clinical situations. In order to provide each resident with a productive, efficient and rich learning experience the following expectations are equally set of all resident rotators.

Core Competencies

Residents spend one month on the Neuro-ICU service in the PGY-II year and 2 months in the PGY-III year. In the first 6-8 months of the year, the PGY-II resident assigned to the Neuro-ICU rotation works with a PGY-III resident. Both the PGY-II and PGY-III residents are supervised by the Neuro-ICU fellows and attendings.

When a PGY-II and a PGY-III resident rotate simultaneously on the Neuro-ICU service, the PGY-III functions as the “senior” resident and is responsible for overseeing and delegating some duties and responsibilities to the PGY-II.
Core competency-based goals for this rotation are as follows:

Patient Care

• During this rotation, basic skills in the diagnosis, evaluation, and management of critically ill neurology patients in the Neuro-ICU will be developed. This will supplement knowledge gained on the inpatient ward. The PGY-III resident provides assistance, guidance, support, and supervision to the PGY-II resident on service early in the year.

Medical Knowledge

• Basic knowledge with regard to neuro-critical care and acute stroke management will be obtained through background reading and bedside teaching. The resident is expected to apply knowledge from evidence-based medicine to patient care.  Knowledge is also gained through didactic teaching.

Interpersonal and Communication Skills

• The resident will present patients to the supervising attending succinctly and completely and will maintain comprehensive, timely, and legible medical records. The resident will communicate effectively with patients, families, and other health professionals and will confer with consultants as necessary. Because of the critical nature of the neuro-ICU patients, effective communication skills are necessary to interact with families and participate in family conferences as necessary.  

Practice-Based Learning and Improvement

• The resident will develop the ability to investigate and evaluate his/her care of patients, to appraise scientific evidence, and to improve patient care based on constant self-evaluation and life-long learning. The supervising attending will ensure that the resident identifies strengths and deficiencies in his/her knowledge and implements changes leading to improvement. The resident will locate and use evidence from scientific studies in his/her care of patients.  The resident will educate patients and their families about the patient’s condition.

Professionalism

• Neurology residents will behave in a professional manner at all times. The highest standards of professionalism must be maintained, especially in interactions with patients or other physicians. The resident will participate in family meetings where important decisions are made pertaining to neuro-ICU patients. The resident will also be responsible for tracking duty hours and reporting them to the Education Administrator and program director. The resident should accomplish all assigned tasks related to clinical patient care within the limitations of the ACGME duty hour regulations.  Chart notes must be completed in a timely fashion.

Systems-Based Practice

• The critically ill patient and the patient with acute stroke require rapid and effective manipulation of the health care system.  The resident will learn and how to provide effective acute therapy. The resident will learn how to appropriately triage severity of illness and handle crises in a timely fashion. The resident will learn how to appropriately utilize ancillary services for optimal patient care.

Goals & Educational Objectives

The neurology resident will be trained in various aspects of neurocritical care and acute stroke directly by the Neuro-ICU Attendings and Fellows. The culture, organization, and extra layers of education and support provided by the Fellows assure a very positive environment, which greatly facilitates the learning experience for the rotating resident(s). This ultimately leads to the neurology resident’s ability to approach and outline the key management issues of major Neuro-ICU syndromes and disease presentations. The resident will observe, understand and execute the preferred management approach for common problems encountered in Neuro-ICU patients and by doing so gain an increasing independence and decision making capacity. In addition, a number of basic literature and key writings will be used to further reinforce the foundation of the clinical practice.

Overall, the resident will have ample occasions to learn and practice clinical neurology by being directly involved in the care of the very sick.

Specifically, among other achievements, the rotation in neurocritical care and acute stroke service will enable the resident to:

• Provide basic neurocritical care to the acutely brain- and/or spinal cord- injured victim.
• Understand the signs, symptoms, and management of intracranial hypertension.
• Employ a sound knowledge base for the recognition and treatment of acute stroke syndromes.
• Delineate the recognition and management of acute intracerebral and subarachnoid hemorrhages.
• Interpret the neuroimaging of acutely brain injured patients.
• Recognize the importance of prognostication in neurocritical care.
• Receive instruction in various aspects of end-of-life palliative care, including pain relief and support for patients and family members.
• Be exposed to various aspects of bioethics.
• Participate in the evaluation of and decision making for patients with disorders of the nervous system requiring surgical management.

Resident Responsibilities

• Start the work day at 6:00am.
• Adhere to the 80 hr/week. This is a very strict policy and exceptions are not permitted. The resident must keep track of his/her own hours and inform the Neuro-ICU staff if he/she is approaching the predetermined work hour limits.
• Work in the ICU six days per week, have one off day in seven, usually on the weekend. The day off-service will be arranged with the Neuro-ICU fellow.
• Gather all information about new admissions to the Neuro-ICU service at the beginning of the day.
• Collect all labs, microbiology and image results.
• Examine the patients and write the daily notes, orders and lab/CXR requisitions for the following day (under the guidance of the fellow).
• Attend the daily bedside rounds to present and discuss the patients, to generate working hypotheses, and treatment plans under the supervision of the fellow/attending.
• Correct abnormal lab values (example, low K+, low Mg++, etc) under the supervision of the fellow.
• Obtain requested consultations and place orders for required tests/studies.
• Perform procedures such as LP, ABG drawing, central venous line/arterial line placement as per Neuro-ICU fellow decision and supervision if needed.
• Update the fellow/attending regarding new patient issues, consultations, etc.
• Additional specific responsibilities will be assigned by the fellows and the attending.

Responsibilities of Neurology Resident-On Call during Neuro-ICU Coverage

• A neuro-ICU fellow is available in-house 24/7. The fellow is responsible for covering the existing neuro-ICU patients and for handling new consults requiring neuro-ICU level care.
• The on-call neurology resident is responsible for handling all neurology admissions to the neuro-ICU between 5:00pm and 7:00am with the assistance of the fellow.
• The resident will write admission orders, H&P on neuro-ICU admissions overnight.

Required Didactics

During the Neuro-ICU rotation, the neurology resident is exposed to a continuum of ongoing learning experiences with specific focus on critically ill patients. Residents should attend all of their regularly scheduled weekly conferences. In addition, while on this rotation residents should plan to attend the following:

• Neurovascular Conference
• NICU Conference
• Stroke Morning Report
• Stroke Noon Report
• Neurology Grand Rounds

Overview

The EEG/Epilepsy rotation takes place in the PGY-III year. This is a six week rotation. The resident is expected to be in the EEG lab and epilepsy monitoring unit daily during weekdays and to participate in the epilepsy clinic once a week.

Core Competencies

Patient Care

• During this rotation, the resident will develop basic skills in the diagnosis, evaluation, and management of patients with epilepsy.  Supervising attendings will evaluate competence in the oral and written presentations of LTM admissions and epilepsy clinic patients.  The attending will also evaluate the resident’s competence in EEG reading and adequate report completion.

Medical Knowledge

• Basic knowledge of EEG and Evoked Potentials interpretation as well as clinical knowledge of the various epilepsies will be obtained during EEG reading sessions, during patient evaluations, through background reading and with reading in a patient-specific fashion. 

Interpersonal and Communication Skills

• The resident will present patients to faculty succinctly and completely, and will communicate clearly with patients, families, staff, and colleagues.   The resident will also participate in EEG reading sessions and present his/her interpretation in a complete and comprehensive fashion.

Practice-Based Learning and Improvement

• The resident will develop the ability to investigate and evaluate his/her care of epilepsy patients, to appraise scientific evidence, and to improve patient care based on constant self-evaluation and life-long learning. The supervising attending will ensure that the resident identifies strengths and deficiencies in his/her knowledge of EEG and epilepsy and implements changes leading to improvement. The resident will locate and use evidence from scientific studies in his/her care of patients.

Professionalism

• Neurology residents will behave in a professional manner at all times. The highest standards of professionalism must be maintained, especially in interactions with patients or other physicians. The resident should accomplish all assigned tasks related to clinical patient care within the limitations of the ACGME duty hour regulations.  Chart notes and EEG reports must be completed in a timely fashion. 

Systems-Based Practice

• The resident will learn the constraints of the health care system placed upon patients with epilepsy, and how to work within these constraints to provide evaluation and management.  Competence will be evaluated by the 360-degree evaluation.

Goals & Educational Objectives

• To become familiar with the range of neurophysiological techniques available for the evaluation of central nervous system function and their applications in the diagnosis and evaluation of patients with neurological diseases.
• To be able to identify EEG abnormalities and the potential clinical correlations of these abnormalities;
• To become familiar with various forms of epilepsy and epilepsy management;
• To understand the usefulness and limitations of evoked potentials in the evaluation of patients with neurological symptoms;
• Residents should have knowledge of the following techniques after completion of the EEG rotation:
  • EEG
  • Evoked potentials
  • Video-EEG monitoring
  • cEEG monitoring in the ICU

Organization

The principal activities for the resident during this rotation include:

• Working with the clinical Neurophysiology technologist to gain understanding of how testing is performed and data gathered.
• Pre-reading EEG studies throughout the day, prior to the formal reading session in the afternoon.
• Working with the fellows and attendings to learn how the data are analyzed and reports are prepared.
• Admitting EMU (epilepsy monitoring unit) patients, writing orders, rounding on these patients and reviewing their EEG recordings daily with the EMU fellow and attending.
• Study of textbooks and the literature.
• Participation in epilepsy clinic one day a week.

Schedule

• Residents pre-read EEGs that are performed daily in preparation for the afternoon EEG reading session with the attending.
• The resident rounds on the EMU patients, reviews their EEG with the fellow and attending and writes daily progress notes.
• Residents review Evoked Potential studies that have been performed with the fellow and attending. 
• Throughout the rotation, unless clinic time is scheduled, residents should participate in the afternoon EEG reading and the EP review sessions.
• In the first part of the rotation the resident has an opportunity to work with the technologists performing EEGs and EPs. The goal is to become minimally proficient in being able to perform these tests.
• Resident presents a Neurophysiology EEG conference at the end of the rotation

Suggested Readings

• Current Practice of Clinical Electroencephalography, 4th Edition, by John S. Ebersole MD, Aatif M. Husain MD, Douglas R. Nordli Jr. MD
• Fisch and Spehlmann's EEG Primer: Basic Principles of Digital and Analog EEG: 3rd (third) Edition by Bruce Fisch.
• Spehlmann's Evoked Potential Primer, 3e by Karl E. Misulis MD PhD, Toufic Fakhoury MD
• Electroencephalography: Basic Principles, Clinical Applications, and Related Fields by Ernst, M.D. Niedermeyer, Fernando Lopes Da, M.D. Silva

Required Didactics

Residents should attend all of their regularly scheduled weekly conferences. In addition, while on this rotation residents should plan to attend the following:

• EEG Boot Camp
• Surgical conference
• Journal Club
• Neuro-ICU EEG Conference
• Neurology Grand Rounds

Overview

The EMG rotation takes place in the PGY-III year. During the four week EMG rotation, the resident will develop an understanding of the neurophysiology of EMG testing, and will perform EMG/nerve conduction studies under the supervision of faculty and the EMG fellow. The resident gets exposure to various neuromuscular diseases during the EMG rotation. The resident is expected to be in the EMG lab four days per week and to participate in the neuromuscular clinic one day per week.

Core Competencies

Patient Care

• During this rotation, the resident will develop basic skills in the diagnosis, evaluation, and management of patients with neuromuscular disease.  Supervising attendings will evaluate the resident’s competence in performing and interpreting EMG/NCS and in their ability to formulate an EMG report. The attending will also evaluate competence in the oral and written presentations of neuromuscular patients seen in the clinic.

Medical Knowledge

• Basic knowledge of the technical aspects and interpretation of EMGs, and basic knowledge pertaining to neuromuscular diseases will be obtained through performance of EMG studies, through patient evaluations in the clinic, and through background reading, with reading in a patient-specific fashion.  The resident will present a neuromuscular case conference at the end of the rotation.

Interpersonal and Communication Skills

• The resident will participate in EMG studies with the attending and will present his/her interpretation in a complete and comprehensive fashion.  The resident will also present neuromuscular clinic patients to faculty succinctly and completely, and will communicate clearly with patients, families, staff, and colleagues.

Practice-Based Learning and Improvement

• The resident will develop the ability to investigate and evaluate his/her care of neuromuscular patients, to appraise scientific evidence, and to improve patient care based on constant self-evaluation and life-long learning. The supervising attending will ensure that the resident identifies strengths and deficiencies in his/her knowledge of neuromuscular diseases and EMG and implements changes leading to improvement. The resident will locate and use evidence from scientific studies in his/her care of patients.

Professionalism

• Neurology residents will behave in a professional manner at all times. The highest standards of professionalism must be maintained, especially in interactions with patients or other physicians.  Clinic notes and EMG reports must be completed in a timely fashion.  

Systems-Based Practice

• The resident will learn the constraints of the health care system placed upon patients with neuromuscular disease, and how to work within these constraints to provide evaluation and management.

Goals & Educational Objectives

• Learn the technical aspects of nerve conduction studies and the needle electrode examination. During the first few days of the rotation, the resident familiarizes him/herself with electrode placement and the needle exam and gradually develop the skills to perform the procedure under supervision.
• Generate a report for each study performed.
• Attend the weekly neuromuscular clinic. Residents are responsible for examining patients, reviewing their records including EMGs, muscle biopsies, and other tests.
• Learn how to apply EMG testing to the care of patients with various neuromuscular diseases in both the outpatient and inpatient settings.
• Sharpen the resident’s knowledge of neuroanatomy and localization in the peripheral nervous system.
• Identify appropriate indications for performing an EMG study.
• Perform and interpret EMG studies for a variety of neurological/neuromuscular diseases.
• Diagnose and manage common neuromuscular diseases.
• Residents are required to give one of the monthly neuromuscular case conferences when they are on this rotation. The format is a brief vignette, pertinent lab results, EMG findings and histological correlation (nerve/muscle biopsy) if applicable. This will be followed by brief literature review.
• The resident will perform an open book pre-test and a closed book post test at the beginning and end of the rotation respectively. The tests are in multiple-choice format and the answers are discussed with the resident.

Required Didactics

• Residents should attend all of their regularly scheduled weekly conferences. In addition, while on this rotation residents should plan to attend the following:
  • Neuromuscular Clinical/Pathology Conference
  • EMG Boot Camp
  • Neurology Grand Rounds

Suggested Readings

• Electromyography and Neuromuscular Disorders, 3rd Edition - Clinical-Electrophysiologic Correlations, By David C. Preston, MD and Barbara E. Shapiro, MD, PhD
• Electrodiagnosis in Diseases of Nerve and Muscle: Principles and Practice by Jun Kimura

Overview

The pediatric neurology rotation gives residents experience with neurological disorders in adolescents, children and infants. The adult neurology residents participate in two months of inpatient and one month of outpatient pediatric neurology under the supervision of our child neurology faculty.

Residents spend one month on the inpatient neurology service in the PGY-II year, another month in the PGY-III year, and one month in the outpatient pediatric neurology clinic in the PGY-III year. At all times, there is a PGY-III and a PGY-II neurology resident on the inpatient pediatric neurology service which covers inpatient pediatric consults and the pediatric neurology inpatient service.

On the inpatient service, the PGY-III resident functions as the "senior" resident and is responsible for overseeing and delegating duties and responsibilities. The PGY-III will assign consults to the PGY-II resident and rotating medical students and general pediatrics residents.

PGY2 Core Competencies

Patient Care

• During this rotation, competence in the care of pediatric neurology patients is developed and demonstrated in the bedside evaluation of patients, in oral case presentations, and in written communications in the patients' chart. The supervising attending will evaluate competence in verbal and written presentations. Clinical skills include the ability to perform a complete history and physical examination in a child, generate a rational differential diagnosis, workup, and management plan, and interpret results of studies in the context of patient care.

Medical Knowledge

• The resident is expected to gradually develop a detailed body of knowledge related to neurological disorders seen in the pediatric population. Medical knowledge is obtained through independent reading of the literature, reading in a patient-specific fashion, and through didactics. Senior residents teach junior residents and medical students. As the year progresses, the junior resident will also be expected to participate in medical student teaching. Teaching skills will be evaluated by the attending physician and by the medical students.

Interpersonal and Communication Skills

• The resident will present patients to the supervising attending succinctly and completely and will maintain comprehensive, timely, and legible medical records. The resident will communicate effectively with patients, families, and other health professionals and will confer with consultants as necessary. The neurology resident will also communicate clearly with the service that requests a pediatric neurology consult. The resident will teach basic neurology to the rotating medical students.

Practice-Based Learning and Improvement

• The resident will develop the ability to investigate and evaluate his/her care of patients, and improve patient care based on constant self-evaluation and life-long learning. The supervising attending will ensure that the resident identifies strengths and deficiencies in his/her knowledge and implements changes leading to improvement. The resident will locate and use evidence from scientific studies in his/her care of patients. The resident will educate patients and their families about the patient's condition.

Professionalism

• Neurology residents will behave in a professional manner at all times, especially in interactions with patients, parents, or other physicians. The resident will be responsible for tracking duty hours and reporting them to the Education Administrator and program director. Chart notes must be completed in a timely fashion. Competence in professionalism will be assessed by supervising attendings.

Systems-Based Practice

• The resident will learn the constraints of acting as a consultant in pediatric neurology and taking care of patients on the pediatric neurology service. The resident will be able to complete the necessary workup, coordinate neurological care to the outpatient setting, and will develop appropriate billing skills.

PGY3 Core Competencies

Patient Care

• While rotating on the inpatient pediatric service, the PGY-III resident functions as the senior resident and provides assistance, guidance, support, and supervision to the PGY-II resident on service. The PGY-III resident takes call from home to cover the service at night.  The PGY-III resident is responsible for overseeing all patient related issues and medical decisions pertaining to patients on service.  The PGY-III resident is given some degree of autonomy by the supervising attending physician to allow the resident to exercise independent judgment and have a supervisory role.

Medical Knowledge

• The resident will continue to develop and refine his/her knowledge in Pediatric Neurology and will teach the junior resident and medical students about various aspects of neurologic disease in the pediatric population.
• Interpersonal and Communication Skills
• The PGY-III resident will routinely discuss the patients on service with the junior resident and medical students and will provide them with bedside teaching. The PGY-III resident will communicate effectively with the attending, patients, families, and other health professionals.

Practice-Based Learning and Improvement

• The resident will continue to develop the ability to investigate and evaluate his/her care of patients, and to improve patient care based on constant self-evaluation and life-long learning. The resident will use evidence from scientific studies in his/her care of patients. The resident will assist the junior resident in educating patients and their families about the patient’s condition.

Professionalism

• The PGY-III resident will behave in a professional manner at all times with junior resident and with patients.  The resident will be responsible for tracking and reporting his/her own duty hours and for ensuring that the PGY-II resident is in compliance with duty hour regulations.

Systems-Based Practice

• The PGY-III resident will teach the junior resident to work as part of a team to enhance patient safety and improve patient care quality.  The PGYIII resident will teach the junior resident to complete the necessary workup and coordinate neurological care in preparation for the outpatient setting.

PGY3 Core Competencies (Out-Patient)

Patient Care

• During this rotation, competence in evaluation and management of pediatric neurology outpatients is developed and demonstrated in oral case presentations, and in written communications in the patients’ chart.  The supervising attending will evaluate competence in verbal and written presentations.

Medical Knowledge

• The resident will develop a detailed body of knowledge related to neurological disorders in the pediatric population by participating in the outpatient pediatric neurology clinic where patients with a variety of neurological disorders are seen.  Medical knowledge is obtained through independent reading of the literature, reading in a patient-specific fashion, and through patient evaluations in the clinic.  The resident is also expected to apply knowledge from evidence-based medicine to patient care.

Interpersonal and Communication Skills

• The resident will present patients to the supervising attending succinctly and completely and will maintain comprehensive, timely, and legible medical records. The resident will communicate effectively with patients, families, referring physicians and other health professionals. The resident will dictate a complete clinic note and letter to the referring physician.

Practice-Based Learning and Improvement

• The resident will develop the ability to investigate and evaluate his/her care of patients, to appraise scientific evidence, and to improve patient care based on constant self-evaluation and life-long learning. The supervising attending will ensure that the resident identifies strengths and deficiencies in his/her knowledge and implements changes leading to improvement. The resident will educate patients and their families about the patient’s condition.

Professionalism

• Neurology residents will behave in a professional manner at all times. The highest standards of professionalism must be maintained, especially in interactions with patients, families, or other physicians. Clinic notes must be completed in a timely fashion.

Systems-Based Practice

• The resident must learn how to manage the time constraints of outpatient practice while delivering tertiary-level care.  The resident will learn how to perform efficient outpatient evaluations and appropriately utilize ancillary services.  The resident will develop appropriate billing skills.

Goals

The overall goals for the three-month Pediatric Neurology rotation are to provide the resident with an opportunity to perfect his/her history-taking skills and neurologic exam in infants and children, to learn about abnormalities of the nervous system at various stages of growth and development, and to provide the resident with an exposure to a wide variety of neurologic problems in infants and children.

• To provide a concentrated exposure to neurologic disorders commonly  encountered in pediatrics, including nervous system disorders requiring surgical or psychiatric evaluation and management.
• To increase the resident’s skills at diagnosing infantile and pediatric seizure disorders and selecting appropriate anticonvulsant therapy.
• To provide an opportunity for residents to pursue directed readings that focus on pathophysiology of pediatric neurologic disease processes.

Educational Objectives

• To develop a logical approach to the evaluation and decision-making when evaluating children with neurologic problems. Following the rotation, residents should be able to obtain a detailed history, as it pertains to the pediatric population, and conduct comprehensive general and neurological examinations.
• To learn to distinguish abnormal from normal patterns of development in the examination of infants and children.
• To learn the indications for and interpretations of CT and MRI scans of pediatric neurologic disorders.
• To learn to manage pediatric patients with neurological problems, especially those with intractable epilepsy, neurogenetic disorders, neuromuscular disorders and neurobehavioral disorders. This will include exposure to basic EEG interpretation (routine and long-term monitoring).
•  To learn to evaluate mental retardation, developmental disabilities, headache, movement disorders, and neurovascular disease.
• Residents should become familiar with the following topics during their time on the rotation through exposure, didactic sessions and readings:
  • Examination of the newborn, child and adolescent
  • Perinatal problems in premature and full term infants
  • Intracranial hemorrhage
  • Brain tumors
  • Developmental delay and mental retardation
  • Pediatric movement disorders
  • Coma and stupor
  • CNS infections
  • Febrile seizures
  • Childhood seizure disorders
  • Pediatric epilepsy surgery
  • Degenerative neurologic diseases
  • Demyelinating disorders
  • Neuromuscular diseases
  • Neurocutaneous diseases (Tuberous sclerosis, Neurofibromatosis)
  • Headaches
  • School problems, learning disabilities and Attention Deficit disorder
  • Behavioral problems
  • Cerebral palsy and management of spasticity
  • Critically ill child
  • Head injuries
  • Strokes in infancy and childhood
  • CNS dysgenesis

Adult Neurology Resident Rotation Expectations

• The Child Neurology rotation is divided into two services: inpatient and outpatient. Each adult neurology resident will spend approximately 8 weeks on the inpatient service and 4 weeks on the outpatient service.
• A PGY-III and PGY-II neurology resident (pediatric or adult) rotate on the inpatient child neurology service. The senior Neurology resident is expected to teach medical students and residents from other services who are rotating on Child Neurology.
• The Neurology resident is expected to attend the weekly Monday didactic pediatric neurology conference, held at noon in addition to the monthly pediatric neurology case conference. The Neurology resident will present at one of the monthly conferences.
• While on the Child Neurology service, the neurology resident will be assigned to "round" on inpatients on weekends. Weekend coverage is shared by the PGY-II and PGY-III residents. Weekend rounds will be scheduled in coordination with the Child Neurology attending physician.
• Read required readings.

Responsibilities of the Neurology Resident

• Out-Patient Pediatric Neurology Rotation
  • The neurology resident will attend each outpatient clinic, except when it conflicts with his or her continuity clinic, and will see patients with child neurology attendings over the course of the week. The clinic schedule is as follows:
  • The resident is expected to see both new and follow-up patients. Each patient will be seen initially by the resident and then will be presented to the attending, who will accompany the resident back to see the patient. The assessment and plan formulated by the resident is discussed and reviewed with the attending.
  • The new and follow-up patients seen in the clinics by the neurology resident are patients of the attending child neurologists.
  • Residents are required to document all patient information appropriately for patients seen in the outpatient clinics. This includes dictation of clinic notes.
  • The residents will use the "no clinic" time to read and complete notes and dictations.
• In-Patient Pediatric Neurology Rotation
  • The PGY-III Neurology resident on the inpatient service is the service senior resident.
  • Residents are expected to work up all patients admitted to or seen in consultation by Child Neurology. This is usually done on the day of admission or consult. Consults requested during the night are handled by the PGY-III resident on home call; if the patient requires an immediate evaluation, the resident will come in to the hospital to evaluate the patient. Child neurology patients and consults are on the regular pediatric units as well as in the Pediatric ICU, and Neonatal ICU.
  • Residents are required to complete consultations on hospitalized patients thoroughly and present them on rounds to the attending.
  • Elective admissions for Video-EEG are performed by the pediatric neurology resident. All scheduled elective Video EEG admissions are handled by the Residents on the Pediatric Neurology service, i.e. writing orders, daily progress notes, discharging patients and dictating discharge summaries.
  • Residents are required to follow the consult patients and communicate recommendations to the inpatient team(s). Patients seen in consultation by the Child Neurology team should have notes written at intervals appropriate to the nature of the patient’s problem.
  • Residents are required to document all patient information appropriately for patients seen on the inpatient service and in consultation include the information in sign-outs.
  • Resident inpatient work rounds will take place every morning. The resident obtains results of tests performed during the previous day including laboratory tests, neuroimaging results and reviewing LTM/EEGs.
  • Residents are required to work with the attending on service to develop an appropriate rounding schedule and review VEEG results.
  • Every day the pediatric neurology team will round at an agreed upon time with the in-patient general pediatric team to discuss patient management.
  • Residents will see and care for pediatric neurology inpatients and provide consultations for inpatients on other services and in the emergency room in a timely manner.
  • Inpatient duties are the primary responsibility of the neurology resident. When an emergency arises, this will take precedence over all other duties of the resident including outpatient responsibilities and conferences (with the only exception being during the time when the resident is in his/her own continuity clinic).
  • The PGYII resident does not take night call on the pediatric neurology service.
  • To supervise the PGYII Neurology resident, general pediatric residents, and medical students in the neurological care of patients.
  • To understand the plan for each child on the pediatric neurology service and to ensure that this plan is actively implemented.
  • To manage the team as a whole and to facilitate interactions between the general pediatric team, subspecialists, RNs, case managers, social workers, and other services.
  • To communicate clearly to the attending of record.
• To teach the PGYII neurology residents and medical students through:
  • Modeling appropriate interactions with patients, families and other staff.
  • Demonstrating neurological examination and history taking skills.
  • Teaching in didactic and clinical settings whenever possible.
  • Teaching procedural skills.
  • Demonstrating use of evidence based medicine in the management of patients.
  • Advocating on behalf of patients and facilitating processes related to their care.
  • To supervise the admission, diagnostic evaluation and treatment of newly admitted patients.
  • To oversee care of all inpatients.
  • To be available for any urgent/emergent situation that arises on the child neurology service, pediatric floor, PICU, NICU or emergency room.
• To communicate with and notify the attending of significant changes in a patient's condition, regardless of the time of day or day of week. There are nine specific situations that automatically qualify as "significant changes" in the patient's condition and require that the resident notify the attending:
  • Admission to the hospital.
  • Transfer of the patient to the intensive care unit.
  • Need for intubation or ventilatory support.
  • Cardiac arrest or significant changes in hemodynamic status.
  • Development of significant neurological changes.
  • Development of major wound complications.
  • Medication errors requiring clinical intervention.
  • Any significant clinical problem that will require an invasive procedure.
  • Any incident which compromises safety, endangers a patient, or causes potential harm.
  • Senior Resident Pediatric Neurology Rotation Responsibilities

Pediatric Neurology Attending Responsibilities

• To have the ultimate responsibility for all medical decisions regarding his/her patients.
• To develop a plan for the medical management of each patient in conjunction with the house staff and consulting services.
• To be responsible for the implementation of the plan of care and for documentation of the plan in the medical record.
• To be responsible for providing oversight and supervision of all care provided by residents.
• To behave in a professional manner at all times with regard to resident supervision.
• To encourage each resident to seek guidance from the attending at any time the resident believes it to be helpful in the care of the patient.
• To respond fully and respectfully to any questions or concerns expressed by the care team, including residents and fellows.
• If the attending physician delegates, in whole or in part, the medical management plan, the attending remains responsible for ensuring that all residents have appropriate training, experience and competence to undertake such management.

Required Didactics

Mandatory conferences (in addition to other mandatory conferences for neurology residents):

• Pediatric Neurology Didactic Conference
• Pediatric Neurology Case Conference (Schorr Rounds)
• Neurology Grand Rounds
• Pediatric Grand Rounds

Suggested Readings

The neurology resident is expected to read about the problems he/she is seeing, in standard pediatric neurology textbooks and in the literature.

• Textbooks include
  • Clinical Pediatric Neurology: A Signs and Symptoms Approach by Gerald M. Fenichel.
  • Child Neurology by John H Menkes, Harvey B Sarnat, and Bernard L. Maria.
  • Residents have access to the Pediatric Library located on the 5th floor of the Children's Hospital.
• Online Learning centers include the:
  • Child Neurology Society homepage – http://www.childneurologysociety.org/
  • Gene Tests homepage – http://www.genetests.org/
  • Online Mendelian Inheritance of Man (OMIM) – http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=OMIM
  • Neuromuscular Disease Center – http://www.neuro.wustl.edu/neuromuscular/
• The neurology resident will be expected to read about the problems he/she is seeing, both in the standard pediatric neurology texts and in the literature. To help with this goal, he/she is given a bibliography of suggested reading in regard to the various categories of neurologic problems in infancy and childhood listed above. Copies of the required readings are available from the neurology staff.

Overview

The Neuropathology rotation is designed to be a comprehensive structured review of all aspects of neuropathology. The rotation is designed as a seminar type course in which the entire spectrum of diseases of the central and peripheral nervous system and skeletal muscle are reviewed in a systematic fashion. This course is structured around daily seminar type discussions using assigned clinical cases with microscopic slides and focused reading assignments in standard neuropathology textbooks. During a scheduled 60-90 minute daily seminar, the residents meet with an attending neuropathologist (or neuropathology fellow) to review the topics for that day focused on the assigned microscopic slides/case studies that illustrate the important features that define the pathogenesis and morphologic pathology for each pathologic entity.

Time and Duration

The formal seminar/discussion sessions are scheduled five days/week. The entire course requires eight weeks to review all topics and residents are encouraged to schedule an additional 2-4 additional weeks to review “unknown” additional case studies that are assigned in a random order, unrelated to specific pathologic categories.

Because the course builds on previously acquired knowledge, all residents must begin at the same time. This course is offered during the Autumn and Spring quarters beginning on the first weekday of October and April. Residents may not begin at other times. Minimum rotation is eight weeks; maximum rotation is 12 weeks.

To allow flexibility in scheduling for other responsibilities (clinic duties, seminars, etc.) the formal didactic seminars are usually scheduled mid-day, between 11:00am and 1:00pm. Glass slides and all necessary textbooks are always available for viewing in Neuropathology office area E607, E609 and must remain in this area. Residents are expected to come to daily noon seminars having reviewed all the assigned slides and reading. Glass slides may be supplemented by electron micrographs and gross photos.

Goals and Educational Objectives

By the end of the course, residents are expected to achieve the appropriate levels of competence in each of the categories outlined by the ACGME. They must

• Be able to arrive at a list of possible diagnoses based on the clinical information (history, radiology, labs) available for a case.
• Arrive at the neuropathologic diagnosis based on clinical information and gross and microscopic pathology available.
• Be familiar with current knowledge about pathogenesis, molecular genetics or epidemiology of each diagnostic entity.
• Be able to discuss current treatment modalities available for each pathologic entity.

Core Competencies

Patient Care

• Residents must demonstrate a satisfactory level of diagnostic competence and the ability to provide appropriate and effective consultation in the context of Neuropathology service.
• Resident knows what clinical information is needed and knows how to obtain essential clinical information in order to render the most useful and accurate diagnostic interpretation of tissue biopsies for the physicians caring for the patient.
• Resident has sufficient understanding of pathogenesis, epidemiology, prognostic implication of diagnostic entity and available treatment modalities to be able to communicate with physicians caring for patient.
• Resident is familiar with the proper handling of neuropathology specimens and is capable of communicating with surgeons, clinicians and technical staff precisely how these specimens should be handled – including brain biopsies for frozen section diagnosis, stereotactic needle biopsies of brain, skeletal muscle biopsies including percutaneous muscle biopsies, peripheral nerve biopsies, muscle for neuromuscular junction pathology, and rectal biopsies for neuronal storage disease.
• Resident recognizes whether tissue is adequate for diagnostic test requested and is capable of communicating with treating physician what type of biopsy tissue is required for specific diagnostic information.

Medical Knowledge

• Residents must demonstrate knowledge about established and evolving biomedical, clinical and cognate (e.g., epidemiological and social-behavioral) sciences and the application of this knowledge to pathology.
• Resident demonstrates basic knowledge of diagnostic and prognostic aspects of neurologic diseases.
• Resident can formulate a differential diagnosis based on analysis of morphologic, clinical and imaging findings.
• Resident effectively participates in daily case discussions.
• Acquires sufficient experience to recognize gross and microscopic appearance of common neuropathologic entities.
• Resident shows improvement in knowledge base during rotation.

Practice-based Learning and Improvement

• Residents must be able to demonstrate the ability to investigate and evaluate their diagnostic and consultative practices, appraise and assimilate scientific evidence and improve their patient care practices.
• Resident looks up information, literature regarding assigned cases and includes references, when appropriate.
• Resident uses recent literature to prepare for daily case discussions.
• Resident independently reviews assigned case studies and pertinent text material.
• Resident responds constructively to criticism designed to improve performance at case discussions.
• Quality of case discussions improves based on knowledge acquired during earlier discussions.

Interpersonal and Communication Skills

• Residents must be able to demonstrate interpersonal and communication skills that result in effective information exchange and teaming with other health care providers, patients and patients’ families.
• Resident analyzes problems and expresses solution in logical, clear and articulate manner.
• Resident demonstrates ability to communicate effectively with clinical staff and laboratory personnel.
• Resident has good relation/rapport with colleagues in rotation and on other clinical services.
• Resident is capable of communicating pathologic findings to treating physicians in a clear and meaningful manner.

Professionalism

• Residents must demonstrate a commitment to carrying out professional responsibilities, adherence to ethical principles, and sensitivity to a diverse patient population.
• Resident is on time for scheduled meetings.
• Resident completes assigned tasks in a timely and thorough manner.
• Resident consistently recognizes that patient care “comes first,” and accepts patient care responsibilities, when assigned, without complaint.
• Resident volunteers to take on additional work.
• Resident understands and adheres to safety procedures.

System-based Practice

• Residents must demonstrate an awareness and responsiveness to the larger context and system of health care and the ability to call on system resources to provide neuropathology services that are of optimal value.
• Understands how neuropathology practice affects other health care professionals, the health care organization, and the larger society and how these elements of the system affect their own practice.
• Knows how types of medical practices and delivery systems differ from one another, including methods of controlling health care costs and allocating resources.
• Practices cost-effective health care and resource allocation that does not compromise quality of care. (Knows which additional tests are necessary to provide optimal information and which are unnecessary and burden laboratory technical staff with time consuming tasks which interfere with efficient work flow.)
• Advocates for quality patient care in dealing with system complexities.
• Knows how to partner with health care managers and health care providers to assess, coordinate, and improve health care and knows how these activities can affect system performance.

Duties and Responsibilities

• Due to the limited amount of time allotted for residency training in neuropathology and the limited variety of material newly accessioned by the neuropathology service during the allotted time period, the neuropathology rotation is essentially didactic, based on archival material. Residents’ primary responsibility is to diligently study the material assigned for daily seminars and be prepared to knowledgeably discuss assigned cases at daily seminar. In addition to daily slide reviews, participation at weekly autopsy brain cutting sessions (Friday 8:00am to 9:30am) and autopsy CNS slide review (Thursday 9:00am to 10:00am) is mandatory.
• Obtaining the six competencies required by the ACGME.
• As iterated above, the neuropathology rotation is a didactic, seminar-type course, where residents are essentially students and do not assume clinical responsibilities as they might on other anatomic pathology rotations. Their sole responsibility is to achieve the competencies broadly outlined by the ACGME and, more specifically outlined under Goals & Objectives, by actively participating in the daily seminars and brain cutting sessions. Active participation means that residents are expected to have reviewed the assigned case material and read the assigned sections in the text before the seminar and, based on the case slide review and reading, be able to knowledgeably discuss the possible differential diagnoses, suggest additional studies necessary to arrive at specific diagnoses, understand the implications of the diagnosis including how treating physicians will use the information transmitted by the neuropathologist based on the above. As part of the case discussion, based on his/her reading, the resident is also expected to know the current information regarding the etiology and pathogenesis of the specific pathologic entity.

Required Didactics

Residents should attend all of their regularly scheduled weekly conferences. In addition, while on this rotation residents should plan to attend the following:

• NeuroSurgery Grand Rounds
• NeuroOncology Conference
• Neuromuscular Clinical/Pathology Conference
• Neurology Grand Rounds

Teaching Staff

• Peter Pytel, M.D.
• Neuropathology Fellow

Evaluation of Residents

To satisfy ACGME requirements, a formal evaluation form will be completed for each resident at the end of the rotation. The most comprehensive evaluation of residents, however, takes place at the daily seminar where residents are expected to discuss the assigned material based on their most recent reading and previously reviewed slides and/or information acquired during previous seminars. During the course and at the end of the course, residents are given a “mini-board exam” with questions designed as much for each resident to evaluate what he or she has learned, as for the faculty to test the effectiveness of the seminar experience.

Curriculum

• Daily Noon Seminar (approximately eight weeks – 40 sessions)
• Orientation
  • Normal neurohistology, cytomorphology
  • Basic neurophysiology, function of neurons, glial cells
  • Basic reaction of neurons and glia to various injuries
  • Microvascular anatomy of CNS – functional blood-brain barrier, choroid plexus
• Vascular Pathology
• Vascular disease – acute infarction – large vessel disease vs. small vessel disease
• Chronologic “repair” of infarction
• Thrombotic vs. emboli vs. hypertensive injury
• Venous infarction
• Atherosclerosis vs. hypertensive arterial sclerosis
• Arteritis
• Vascular disease of spinal cord including arteritis
• Vascular pathology of premature infant – germinal matrix hemorrhage, periventricular leukomalacia, pathogenesis, acute pathology, sequalae-hydrocephalus
• Vascular pathology of term infant
• Cerebral hemorrhage – pathogenesis – anatomic pathology; hemorrhage vs. hemorrhagic infarction
• Vascular malformations – anatomic definitions
• Pathology and pathogenesis of closed head injury – contusion, contrecoup inertial injury, axonal injury
• Malformations
• Neural tube defects – encephalocele, myelocele – tethered cord
• Chiari malformation
• Syringomyelia
• Migrational defects; Holoprosencephaly - Pachygyria – Polymicrogyria
• Cortical dysplasia – tuberous sclerosis – Heterotopias
• Hippocampal sclerosis
• Dandy-Walker
• Sturge-Weber
• Bacterial meningitis – Pathogenesis –Sequelae
• Bacterial abscess – Pathogenesis – Sequalae
• Bacterial “encephalitis” – Spirochete’s, Whipple’s, etc.
• Mycobacterial infection – TB meningitis
• Fungal infections
• Unicellular and multicellular parasites
• Acute viral encephalitis; seasonal arbovirus vs. non-seasonal Herpes encephalitis
• Viral infections – Immunocompromised vs. immunocompetent
• PML, CMV, HZ
• Differential of CNS – pathology of immunocompromised
• Other virus – paramyxovirus, poliovirus, rabies
• Prion diseases (CJD, GSS, FFI, variant CJD)
• Multiple sclerosis – anatomic pathology – pathogenesis, myelin vs. axonal pathology
• Other demyelinating diseases – Devic’s, ADEM, AHLE
• Acquired – CPM – delayed CO, hypoxemia
• Inherited leukodystrophy – classification – metabolic defect
• Hypoxemia (non-infarction) – Basal ganglia, demyelination
• CO, methanol, cyanide, ethanol, lead
• Drugs – antineoplastic and immunosuppressive
• Metabolic encephalopathy – liver and renal failure, Reye’s
• Metabolic myelopathy
• Hypoglycemia
• Hereditary – Wilson’s, Menke’s
• Electrolyte (central pontine myelinolysis)
• Trauma
• Infectious
• Demyelinating Disease
• Toxic Encephalopathy

Overview

The ability to properly interpret neuroradiological studies is crucial for the neurologist in training.  Neuroradiology is an important discipline for the neurology resident to become proficient in.

PGY-II residents spend 2 weeks rotating in neuroradiology. Residents should familiarize themselves with the interpretation of various neuro-imaging modalities including CT, MRI, MRA, and angiography.

The neurology resident rotating through neuroradiology attends the daily morning and afternoon reading sessions with the attending neuroradiologists, fellows and radiology residents.  The neurology resident pre-reads studies with the radiology resident and/or neuroradiology fellow starting at 8:00 am daily, Monday through Friday, prior to the attending reading sessions.  The neurology resident also has an opportunity to observe various procedures such as myelograms, angiograms, and neuro-intervention procedures.

Core Competencies

Patient Care

• During this rotation, basic skills in neuroradiology will be developed.  The resident must learn how to relate radiologic findings to the clinical diagnosis and proper management of patients with various neurologic diseases.  Supervisory attendings will evaluate competence in interpretation of studies and will complete resident evaluations.

Medical Knowledge

• Basic knowledge with regard to performance and interpretation of neuroradiologic tests will be obtained through clinical exposure and background reading.

Interpersonal and Communication Skills

• The resident will participate in reading sessions with the neuroradiology residents and attendings and will communicate with them in a clear and effective fashion.

Practice-Based Learning and Improvement

• The resident will develop the ability to identify his/her strengths and deficiencies in interpretation of radiologic studies, and improve their knowledge base with constant self-evaluation and life-long learning. The resident will identify strengths and deficiencies in his/her knowledge and implement changes leading to improvement.

Professionalism

• Neurology residents will behave in a professional manner at all times. The highest standards of professionalism must be maintained, especially in interactions with patients, parents, or other physicians. Competence in professionalism will be assessed by supervising attendings.

Systems-Based Practice

• System issues related to ordering, performing, and reporting results of radiologic tests will be addressed.  The resident will learn how to most effectively work with radiology to provide effective evaluation and management to patients.

Goals & Educational Objectives

At the end of this rotation, the resident should be able to:

• Develop a methodological approach to film interpretation and identify all pertinent findings in neuroradiologic studies.
• Understand the limitations of each procedure.
• Generate appropriate differential diagnoses based upon neuroradiologic findings.
• Describe strengths and limitations of current neuroradiologic studies.
• Develop independence in interpretation of neuroradiologic studies.

Required Didactics

Residents should attend all of their regularly scheduled weekly conferences. In addition, while on this rotation residents should plan to attend the following:

• Neurovascular Conference
• NeuroOncology Conference
• Neuroradiology Conference
• Reading Conference
• Neurology Grand Rounds

Goals & Educational Objectives

This rotation was established as a result of the new neurology RRC guidelines, which mandate a one-month rotation in Psychiatry, under the direction of a board-certified psychiatrist. This rotation will consist of two two-week blocks on the Inpatient Consult Liaison Service at The UCMC. Descriptions of the rotation, as well as specific learning objectives, are listed below.

Patients with neurological disease often have psychiatric co-morbidities. A neurology resident must have an excellent understanding of psychiatric disease and the ability to provide basic care for patients with psychiatric illness. We also must adequately prepare our residents for the board certification examination (approximately 25% or more of the written board examination tests knowledge of psychiatric disease). To achieve the goals of providing better care for patients with neurological and psychiatric disease, we require that our residents develop the clinical and interpersonal skills needed to care for patients with psychiatric disease. The resident must develop the knowledge base required for a good understanding of the mechanisms, diagnosis of, and treatment of patients with psychiatric disease.

Team Structure

The Psychiatry Consultation Service is made up of an attending physician, resident physicians and medical students. The resident physicians include one to two PGY-II residents from the Department of Psychiatry, and one Neurology resident.

The rotation for Neurology residents is directed towards understanding the fundamentals of performing a psychiatric consultation and/or psychiatric evaluation in general. Experience is provided by performing independent psychiatric consultations in queue with the psychiatry residents and medical students. Neurology residents are considered an equal part of the team and are expected to perform identical consultations and follow-up of existing cases as other members of the team. Detailed assessments and methods of obtaining thorough psychiatric histories will be generated by experience and supervision with the attending physician. Attempts will be made to link the inpatient psychiatric consultation with a more global understanding of outpatient psychiatric management (pharmacologic and/or psychotherapeutic), which is certainly of value upon completion of the Neurology residency.

Neurology residents rotating on the Consultation Service have additional clinical responsibilities and didactics (as do psychiatry residents) and shall be permitted to attend and perform such needs when scheduled. Neurology residents shall expect to rotate in the queue of clinical consultations as directed by the PGY-II CL resident. Neurology residents are also responsible to cover and respond to the Consultation Service pager on a rotating basis, in times of need because of other team members' schedules.

Core Competencies

Patient Care

• Fully gather data from all available sources, including the patient, paper and electronic chart (including physician's notes, nursing staff notes, social work notes, other staff member notes, medication administration records), hospital staff, and family or friends of the patient.
• Adapt one's interview style to suit the clinical setting and medical and/or psychiatric condition of the patient (i.e. communicate effectively with patients on ventilators, recognize stress and fatigue in patients, communicate effectively with difficult or agitated patients, prioritize questions and perform multiple, brief interviews if necessary).
• Ascertain all required information related to a patient's family history, personal history, substance history, premorbid personality, allergies, past medical history, current medications, review of systems, detailed past psychiatric history, detailed history of present illness (including history of present medical illness), and mental status examination, including MMSE.
• Thoroughly formulate a patient's case based upon the above information with particular consideration to perspectives of disease, temperament, behaviors, and life story.
• Comprehensively assess self-injury risk, risk of injury to others, dangerousness and appropriate use of constant observation.
• Accurately assess patients for capacity to make medical decisions ("competency") in medically ill patients.
• Perform routine follow up of already evaluated patients, monitor the patient's course during hospitalization and provide continuing input (both pharmacologic and psychotherapeutic) as needed to the patient and treating team.
• Demonstrate improvement in formulative abilities with progressive experience on the consultation service.
• Accurately and fully document all elements described above on the Resident Physician Consultation Form as well as the patient's chart, including medical and legal facets, when necessary.
• Remain aware of the overall medical status of the patient and general disposition plans as the patient's hospital course proceeds.

Interpersonal and Communication Skills

• Facilitate the requesting service's ability to formulate a clinical question relevant to our capacity to aid in the care of the patient.
• Directly and promptly reply verbally to the consulting service the clinical impression of the patient as well as specific treatment recommendations and guidelines.
• Document in the medical chart all follow-up evaluations of patients remaining in the general hospital, including subjective matters, mental status exam and MMSE (if needed in follow-up), continued assessment as well as ongoing recommendations.
• Advise and guide requesting services about the role of medical disease in a patient's presentation, further diagnostic testing required to clarify the clinical picture and medications that are accordingly recommended.
• Advise and educate requesting services about the current diagnostic assessment of the patient and, if applicable, how it may be distinguished from the team's assessment prior to psychiatric consultation.
• Work as a valued member of a multidisciplinary team to maximize the care of complex medically ill patients.
• Provide appropriate direction to consulting services regarding management of dangerous, agitated and/or psychotic patients who are treated on general hospital units.
• Develop a therapeutic alliance with respect for privacy in medically ill patients.
• Further develop interdepartmental alliances via serving as a respected medical colleague in the hospital.
• Understand the indications for a variety of somatic therapies in medical and surgical patients.
• Understand the use of psychotropic medications and ECT in medical and surgical patients and appreciate physiologic effects, contraindications, drug interactions, and dosing concerns.
• Understand the use of psychosocial treatments including supportive psychotherapy, behavioral management techniques, family therapy, and psychoeducation.
• Understand risk factors, recent precipitants, classical and atypical presentations, screening tests, etiologies, appropriate medical evaluation, and the comprehensive treatment strategies of delirium.
• Effectively advise medical and surgical teams on appropriate use of antipsychotics and benzodiazepines in agitated patients.
• Understand how to perform a comprehensive evaluation for organic causes of psychiatric symptoms or syndromes.
• Distinguish demoralization from other depressive syndromes in the medical setting.

Medical Knowledge

• Understand the medications that have psychiatric symptoms as side effects.
• Understand classes of or specific drug interactions between psychotropic medications and non-psychotropic medications.
• Understand the appropriate indications and dosing strategies for psychostimulants in the medically ill.
• Understand the clinical settings that further justify continued medical or surgical inpatient admission while a patient's disposition is coordinated.
• Understand the appropriate use, risks and benefits, and dosing strategies of psychotropic medications in pregnancy.
• Understand the clinical syndrome of NMS and appreciate its evaluation and management.
• Understand how to perform a pre-transplant psychiatric evaluation.
• Understand the differences between somatization disorder, conversion disorder, factitious disorder and malingering.
• Understand the core concepts of competency and the legal process that may be invoked once a patient has been deemed incompetent.

Professionalism

• Dress in professional business attire at all times defined as:
  • Wearing a clean white coat in all clinical settings involving contact with medical colleagues or patients.
  • Wearing a necktie for gentleman rotating on the service.
  • Replacing scrub outfits with standard professional work attire when post-call.
• Obtain and provide cross-coverage as needed during one's absence or during other scheduled clinical responsibilities.
• Behave collegially and demonstrate willingness to help other members of the team and other departments.
• Assist with and ask for assistance in the case of emergencies or clinical uncertainty.
• Maintain a thorough list of current patients being followed on the consultation service, addressing pertinent issues for patients, including current medication regimens.
• Demonstrate a commitment to ethical principles when dealing with patients, families, and colleagues.

Systems Based Practice

• The patient with psychiatric disease has unique constraints placed upon them by our health care system, and the residents will learn about the barriers that exist and how to work within these constraints to provide effective psychiatric evaluation and management.

Consultation Principles for Residents and Medical Students

Before going to do any consultation during working hours the resident or medical student who is first assigned to the case should check in the case files to see if there have been any prior consultations done on the patient by the CL service. Residents and medical students shall utilize the form titled Resident Physician Consultation Form when performing inpatient consultations. Medical students are invited to use the form and are welcome to submit it as part of the medical record. In this instance, the form must be signed by the resident physician and edited accordingly in the event of variance in clinical documentation when compared to the resident physician's examination of the patient. A Resident MUST ALWAYS fill out their own Resident Physician Consultation Form and MUST ALWAYS read and document by co-signing any note that a medical student writes in the chart.

All areas of the Resident Physician Consultation Form must be completed on every patient. In the event that a particular detail or element of the patient's history is unknown because of an inability to acquire such information, this should be noted accordingly, rather than leaving that section blank. Blank areas are presumed to be consistent with lack of inquiry and are below the standard of care expected on this service. Please note that all patients being evaluated must have a full mental status examination, as well as a Mini-Mental Status Examination without exception. The assessment and recommendation sections of the Resident Physician Consultation Form are equally important in this regard. Formulations must be noted and/or amended after discussion with the attending physician and clearly documented on the Resident Physician Consultation Form. In addition, a complete diagnostic description in the space provided must be documented, as well as a thorough description of the recommendations. These items must be noted despite similar documentation on the Attending Physician Consultation Form.

One area of particular importance that is often neglected in other disciplines of medicine is a thorough and detailed substance history. When performing psychiatry consultations, residents and medical students are expected to take this degree of history, regardless of what may be documented elsewhere in the patient's medical/surgical chart. The following format will provide an easy manner of both asking questions of the patient and provide a thorough understanding of a patient's substance history. Documenting a "social only" history of any substance is inadequate and requires further inquiry for our purposes.

Starting with tobacco, alcohol and progressing to other substances of use (marijuana, cocaine, heroin, speed, MDMA, GHB, etc.), the evaluator shall document and present the details as follows:

• Age of first use.
• Age of most recent use (or ongoing use to the present time).
• Current amount or quantity of use per event or day [be specific about type of substance used (beer vs. whiskey, fortified wine vs. standard wine, cocaine vs. crack cocaine, marijuana joints vs. blunts vs. bowls)].
• Maximum amount or quantity of use per event or day.
• Last use and amount or quantity of use.
• Method(s) of use.
• Withdrawal symptoms present on discontinuation for each substance.
• Presence or absence of blackouts related to alcohol.
• Prior formal detoxification and/or rehabilitative measures for the substance.
• Maintenance medications for drug substitution and elimination of cravings.
• Pharmacologic interventions to encourage abstinence or avoidance of the substance.

Medications documented on the Resident Physician Consultation Form shall be a current listing (as of the instant you evaluated the patient) of all the patient's medications in the hospital. This must include all medications (not just psychotropics) and respective doses and frequencies of administration. It should be endeavored to cluster psychotropic medications together when documenting and reviewing the full medication listing for your benefit. As needed or "prn" medications should be documented and grouped together after all regularly administered medications. Prn medications should be noted with the same criteria of dose and frequency. In particular for psychotropic prn medications, the regularity of the actual administration and total dosing per day shall be noted over at least the past 48 hours and/or a reasonable assessment over the entire hospital stay. Medications (generally psychotropics) that patients had recently been taking at home are best included at the terminus of the past psychiatric history as this was the most recent prescription or suggestion by outpatient providers.

Past psychiatric history shall be a chronological prospective description of the patient's course. One shall note the first contact with a psychiatrist, psychiatric admission and/or episode. This should be described in detail with the presenting symptoms, the diagnosis given, duration of admission and treatment(s) provided. The past psychiatric history shall progressively flow forward in time itemizing each subsequent change in status, admission, new diagnosis or change in medications. Justification of diagnoses should be pursued, including similarity or dissimilarity of symptoms to those previously noted. If patients have been admitted to The UCMC W3 inpatient unit in the past, it is imperative to obtain those records, review them, and include them in your documentation prior to presenting the case.

Salient items to consider and document when reviewing one's past psychiatric history (particularly for a patients who appear to have none of the above) are the presence of mood syndromes such as depression, mania or mixed states. Review of such syndromes with patients is imperative. In addition, documentation of any prior suicide attempt is necessary for every patient. If suicide was attempted, one must note the events surrounding the incident, method of the attempt, and medical or psychiatric sequelae thereof. Current psychiatric contact is necessary to document, as well as location/name of the provider.

It is preferable when considering past psychiatric history to use the same unit of measurement of time for clarity (convert historical dates into either dates/years or age of the patient at that time). This is not always critical, but will prove highly useful in patients who have extensive psychiatric histories, and is a good habit to start practicing.

The history of present illness shall naturally flow from the preceding elements above. For consultation purposes, the history of present illness must include a full understanding of the patient's medical or surgical presentation. The first part of the history of present illness shall document the date of admission and the reason for admission. A review of the Emergency Department and inpatient course is necessary, including important medications being given, and the series of tests or procedures performed to evaluate the patient until the date of consultation. Surgical procedures and complications shall also be noted, including dates performed. This shall also note the presumed diagnosis given by the inpatient service. One shall be able to speak fluently about the elements of the patient's medical or surgical admission.

The next major section of the history of present illness is the description of the reason for the consultation. There may be some overlap with the above history, however, one should delineate these as best possible. The chronological development of symptoms in the patient shall be noted, including the progressing assessment and specific concern of the team requesting the consultation. Information related to this shall be obtained by a detailed chart review, which must include scanning each entry in the chart. Nursing notes and social work notes sometimes have more details pertinent to our assessment of patients and provide a near 24 hour assessment of the patient while the team's physicians are away. Finally, a subjective account of the patient's experience and symptoms shall then be pursued to follow up on all of the items noted above. Screening for current psychiatric disorders shall also be noted.

Laboratory studies and other diagnostic evaluations must be reviewed in detail when performing psychiatric consultations. A review of only the last day or two is inadequate. Unless the patient's admission is so extensive (multiple weeks to months) that a daily evaluation of laboratory studies is laborious and unlikely helpful, all tests and diagnostic findings shall be noted. This includes all imaging reports, cardiac evaluations (including EKG) and others. One shall scan for all usual tests relevant for psychiatric consultations and note the presence or absence of them accordingly. As a general rule, tests to consider include CBC, BMP with LFTs (CMP), magnesium, phosphate, thyroid function profile (usually just TSH), RPR, vitamin B12, toxicology screen, urinalysis and serum alcohol level.

After evaluating the patient with the attending physician, team members shall perform the following:

• Make two copies of the Resident Physician Consultation Form.
• Attach a copy of the Attending Physician Consultation Form to each Resident Physician Consultation Form.
• Place the original Attending and Resident Physician Consultation Forms in the appropriate section of the patient's chart.
• Contact the requesting team by phone to provide a diagnostic review of the case, any recommendations, and answer further questions that may arise.
• Give both copies of the Attending and Resident Physician Consultation Form to Jean Harris in Room M-316 by the next business day (may slide under door if not there).
• Update the list of Consultation Service patients currently being followed.

All patients who have been seen with the attending physician must be followed daily by the members of the team. Patients will be followed daily until there is no further need, as determined by the attending physician. In nearly all cases, patients will be followed by the resident performing the evaluation. Each follow-up visit must be accompanied by a note within the patient's chart. The follow-up notation(s) must review the patient's subjective account of symptoms and notation of recent events since the previous day (as it pertains to the reason for consultation), a mental status examination (including Mini-Mental Status Examination when necessary), a brief review of the assessment of the case, and ongoing treatment recommendations. All follow-up patients must be discussed daily with the attending physician during rounds. Ongoing medical circumstances and additional medical tests should be well-understood by those performing follow-up assessments, including tracking laboratory studies or diagnostic tests. In the event of vacation, absence or rotation off the service, cases will be redistributed accordingly. This involves providing adequate information related to the history, diagnosis, recommendations, and particular areas to monitor for new team members.

On the first day of the rotation for all team members, the PGY-II CL Psychiatry resident will collect the vacation, clinic, and didactic schedules from all residents and students. The PGY-II CL resident will complete a spreadsheet listing the weekly schedule for all team members, including documentation of required absence for vacation, clinical responsibilities, or didactic sessions. Based upon this schedule, the daily Consultation Service pager coverage schedule will then be determined. This schedule will then be published for all team members to review, as well as to clarify one's responsibilities on any given day.

Required Didactics

Residents should attend all of their regularly scheduled weekly conferences. In addition, while on this rotation residents should plan to attend the following:

• Psychiatry Morning Report
• Psychiatry Clinical Case Discussions
• Professor's Rounds
• Psychiatry Grand Rounds
• Neurology Grand Rounds
• C/L & ER Case Conference

Recommended Reading

• Chapters from The Massachusetts General Hospital Handbook of General Hospital Psychiatry (5th Edition) By Stern and Fricchione:
• Approach to Consultation
• Mood disordered patients
• Delirious patients
• Anxious patients
• Psychopharmacologic Issues in the Medical setting
• Difficult patients
• Patients with neurological conditions (2 chapters)
• Patients with cancer and the evolution of the Role of Psychiatry in Oncology
• Patients with HIV infection and AIDS

Overview and Guidelines

Each resident has an outpatient general neurology continuity clinic throughout the three years of residency. It is half a day of clinic per week. Each resident is assigned to work with an attending. Residents will see a variety of general neurology patients. A full history and complete neurological evaluation is required for all new patients with a focused history and physical for follow-up patients.

The outpatient resident continuity clinic schedule is gradually expanded over the first few weeks of residency. PGY-II clinics start initially with 1 new and 2 return patients for a period of 6 weeks, then 2 new and 2 return patients for the rest of that year. PGY-IIIs and PGY-IVs see 2 new and 4 return patients in their clinics.

As residents progress in their training, they become more autonomous and independent in their decision-making and are given more latitude by their clinic attending.

Each patient is evaluated and examined by the resident who subsequently presents the case to the attending. The resident is asked to localize the lesion, generate a differential diagnosis and suggest a plan of evaluation and treatment for the patient. If tests are ordered, it is the resident's responsibility to follow up on them in a timely fashion. For all patients, notes must be completed in EPIC; the notes have to be comprehensive and should include a detailed history, pertinent test results, examination, differential diagnosis and management plan. In general, the resident has primary responsibility for the ongoing neurological management of their patients at all times. The clinic attending physician is always available for consultation regarding patient care. Residents may not change their clinic schedules without prior approval of their clinic attending. Once a change is approved, the resident informs the scheduling staff about the change. The resident must communicate with and inform the clinic coordinators of vacation periods and other time away from the clinic, at least one month in advance.

Continuity Clinic is cancelled during the week of night-float and after overnight buddy call.

Residents are expected to follow in their own continuity clinic patients that they treated as inpatients or in the emergency department. The neurology resident must ensure that patients have a scheduled follow-up clinic appointment in his/her clinic at the time of hospital discharge.

It is the responsibility of the resident to see patients in a timely manner and to arrive to clinic on time.

Follow-up patient appointments are scheduled at checkout from the clinic. If the hour is late and an appointment cannot be scheduled at checkout, please ask the clinic coordinator to call the patient the following day.

Test scheduling: An order must be completed in EPIC by the resident for each requested test in order for the test to be scheduled by our clinic coordinators. Coordinators cannot schedule tests without a properly completed order.

Patients seen in the resident continuity clinic consider the resident as his/her patient's primary neurologist. Several procedures follow:

• Residents must be available by pager to their patients in the event of an emergency and sign their pager out when not on call to the on-call resident. When residents are unavailable, as during required time off from work or vacation, they must arrange backup coverage.
• Patients are also able to contact the resident by leaving a message on the resident's voicemail. Residents should check their voicemail daily. All non-urgent messages should be addressed within 24 hours.
• When on vacation, residents need to provide coverage for their pager and voicemail.

Core Competencies

Patient Care

• In the weekly continuity clinic, competence is developed and demonstrated in evaluation and management of patients, in oral case presentations, and in written communications in the patients' chart. The supervising attending will evaluate competence in verbal and written presentations. Clinical skills include the ability to perform a complete history and physical examination, generate a rational differential diagnosis, workup and management plan, and interpret results of studies in the context of patient care. The resident will follow up his/her patients' test results and will return patient calls in a timely fashion. In the continuity clinic, the resident assumes the primary care of his/her patients. The supervising attending physician discusses care issues in detail with junior residents but will allow greater independence in decision-making when working with senior residents.

Medical Knowledge

• The resident will develop a detailed body of knowledge related to neurological disorders seen in the outpatient general neurology clinic. Medical knowledge is obtained through independent reading of the literature, reading in a patient-specific fashion, and through patient evaluations in the clinic. The resident is also expected to apply knowledge from evidence-based medicine to patient care. Teaching skills will be evaluated by the attending physician, when medical students rotate in the clinic.

Interpersonal and Communication Skills

• The resident will present patients to the supervising attending succinctly and completely and will maintain comprehensive, timely, and legible medical records. The resident will communicate effectively with patients, families, referring physicians and other health professionals. The resident will complete a clinic note in EPIC in a timely fashion and forward it to the attending for final submission.

Practice-Based Learning and Improvement

• The resident will develop the ability to investigate and evaluate his/her care of patients, to appraise scientific evidence, and to improve patient care based on constant self-evaluation and life-long learning. The supervising attending will ensure that the resident identifies strengths and deficiencies in his/her knowledge and implements changes leading to improvement. The resident will locate and use evidence from scientific studies in his/her care of patients. The resident will educate patients and their families about the patient's condition.

Professionalism

• Neurology residents will behave in a professional manner at all times. The highest standards of professionalism must be maintained, especially in interactions with patients, families, or other physicians. Clinic notes must be completed in a timely fashion. Competence in professionalism will be assessed by supervising attendings, as well as by the 360-degree evaluation.

Systems-Based Practice

• The outpatient subspecialty practice of neurology is different from inpatient care. The resident must learn how to manage the time constraints of outpatient practice while delivering tertiary-level care. The resident will learn how to perform efficient outpatient evaluations and appropriately utilize ancillary services. The resident will develop appropriate billing skills.

Goals

• To expose the resident to a broad spectrum of outpatient neurological, neurosurgical, and neuro-medical conditions.
• To see the long term consequences and evolution of neurological disorders and learn to manage them.
• To learn how to function as a specialist and communicate with referring physicians.
• To complete a comprehensive clinic note in EPIC for each patient (including letters to referring physicians) with detailed impression and plan, and follow up patient tests results in a timely manner.
• To assume responsibility for clinic patients.
• Become familiar with and develop competence in communicating with clinic patients by phone, triaging their complaints and handling their concerns. The resident's clinic attending is always available for assistance and advice.

Educational Objectives

• To gain a broad and deep understanding of neurological disorders and master the neurological history and physical exam.
• To develop detailed knowledge of each condition encountered.
• To learn a logical approach to differential diagnosis, evaluation, and management.
• To learn indications for, and interpretation of, various tests such as EMG/NCV, CT, MRI, EEG, sleep studies, various blood tests, genetic tests, etc.
• To learn time management in an outpatient setting to maintain efficient patient flow in clinic.
• To learn responsibility for clinic schedules.

Learn more about our clinical programs and subspecialty clinics here: Clinical Programs

Overview

The outpatient clinic (OPC) rotation occurs during the final year of training. The resident is in the outpatient clinic five days a week between 8:00am and 5:00pm. During this rotation, the resident participates in 3 major areas: subspecialty clinics, urgent neurology clinic and lumbar punctures.

• Subspecialty clinics: the resident participates in ataxia clinic on Monday mornings, movement disorders clinic on Wednesday mornings and dementia clinic on Friday mornings. The resident can also join the subspecialty clinic of his/her choice at any other time if nothing else is scheduled.
• Urgent/semi-urgent patients: the point of this experience is to see patients with urgent neurological problems in the outpatient setting which requires a high level of decision making with respect to telephone triage and deciding on the timing of evaluation and treatment needed.  Every patient evaluated and examined by the resident is subsequently presented to, and seen by, the attending.
• Elective lumbar punctures: these are scheduled by various attendings to be done by the OPC resident.

Core Competencies

Patient Care

• During this rotation, competence in evaluation and management of neurology outpatients (urgent patients and subspecialty patients) is developed and demonstrated in oral case presentations, and in written communications in the patients’ chart.  The supervising attending will evaluate competence in verbal and written presentations.  Clinical skills include the ability to perform a complete history and physical examination, generate a rational differential diagnosis, workup and management plan, and interpret results of studies in the context of patient care. During this rotation, the resident will also learn to triage and manage urgent neurological issues in the outpatient clinic. 

Medical Knowledge

• The resident will develop a detailed body of knowledge related to neurological disorders seen in the urgent and subspecialty clinics.  Medical knowledge is obtained through independent reading of the literature, reading in a patient-specific fashion, and through patient evaluations in the clinic.  The resident is also expected to apply knowledge from evidence-based medicine to patient care.  During this rotation, the PGY-IV resident gives biweekly basic neurology lectures to the rotating medical students. Teaching skills will be evaluated by the attending physician and by the medical students.

Interpersonal and Communication Skills

• The resident will present patients to the supervising attending succinctly and completely and will maintain comprehensive, timely, and legible medical records. The resident will communicate effectively with patients, families, referring physicians and other health professionals. The resident will dictate a complete clinic note and letter to the referring physician.

Practice-Based Learning and Improvement

• The resident will develop the ability to investigate and evaluate his/her care of patients, to appraise scientific evidence, and to improve patient care based on constant self-evaluation and life-long learning. The supervising attending will ensure that the resident identifies strengths and deficiencies in his/her knowledge and implements changes leading to improvement. The resident will locate and use evidence from scientific studies in his/her care of patients.  The resident will educate patients and their families about the patient’s condition.

Professionalism

• Neurology residents will behave in a professional manner at all times. The highest standards of professionalism must be maintained, especially in interactions with patients, families, or other physicians. Clinic notes must be completed in a timely fashion.

Systems-Based Practice

• The outpatient subspecialty practice of neurology is different from inpatient care.  The resident must learn how to manage the time constraints of outpatient practice while delivering tertiary-level care.  The resident will learn how to perform efficient outpatient evaluations and appropriately utilize ancillary services.  The resident will develop appropriate billing skills. 

Goals & Educational Objectives

The OPC rotation consists of 2.5 months divided into two-week blocks throughout the final year of residency. The resident is in the outpatient clinic five days a week between 8:00am and 5:00pm.

The resident will participate in subspecialty clinic from 8:00am to 12:00pm on Monday, Wednesday and Friday and at any other time if nothing else is scheduled. Elective outpatient lumbar punctures are done by the OPC resident. The OPC resident will also schedule urgent general neurology patients in the afternoon. The goals of this rotation include:

• Exposure to outpatient urgent care neurology.
• Triage telephone calls from referring physicians and patients both outside and inside The UCMC.
• See patients in an expedient manner; develop a management plan and then present to the OPC attending.
• Timely communication back to the referring physician.
• Follow-up on test results and disposition.
• Participate in various subspecialty clinics.
• Refine lumbar puncture skills.
• Educational Objectives:
• Learn to triage and manage urgent neurological issues in the outpatient clinic.
• Refinement of history, physical and management skills.
• Communication skills with colleagues.
• Gain experience in evaluating patients with various neurological disorders epilepsy, neuromuscular disorders, MS, dementia, neurodegenerative disorders, movement disorders, ataxia, brain tumors.
• To allow the PGY-IV resident to mature by exercising independent judgment in outpatient assignments.
• To prepare the resident for practice beyond residency, as neurology is largely a referral specialty.

OPC Resident Responsibilities

• During the OPC rotation the mornings will consist of seeing patients in outpatient subspecialty clinics. Urgent neurology patients are generally seen in the afternoon or as the need arises.
• The OPC resident is responsible for covering urgent outpatient neurology consults from all outpatient clinics, including Urgent Care, and facilitating any necessary admissions to neurology.
• If tests are ordered, it is the resident’s responsibility to follow up on them in a timely fashion.
• The resident is responsible for dictating a clinic note for all patients seen in clinic (new and return patients).
• Schedule urgent patients in a timely fashion.
• Communicate the visit outcome to the referring physician as soon as possible.
• To perform lumbar punctures referred by attending physicians. These are preferentially done on Thursdays due to room availability.
• To facilitate admissions coming from the OPC clinic.
• The OPC resident is responsible for giving lectures to the third year medical students rotating through the neurology service. This consists of two lectures per week from a preset lecture schedule.

Overview

The PGY-II neurology resident rotation will take place at primarily the Glenbrook campus, but also at the Evanston Campus for a duration of 2 months. The resident will be involved in multidisciplinary outpatient neurology specialty clinics where they will be assigned to a particular specialty clinic on a daily basis divided into half day blocks. During each half day block, a patient will be scheduled specifically for the resident and will be staffed by the appropriate staff for that subspecialty. The resident will be responsible for evaluating the patient and developing diagnostic and therapeutic management plans for these patients in collaboration with the attending. The rest of the clinic time, outside of the booked resident patient, the resident will be expected to observe and participate in the attending’s clinic.

The rotating resident will be expected to do the following:

• The rotating resident participates in the provision of outpatient care particular to the subspecialty clinic in which they are assigned.
• The rotating resident will expand their knowledge base on the full spectrum of both general and sub-specialty neurological diseases.
• The rotating resident will learn to broaden their differentials diagnosis based on patients presenting symptoms. The will also learn the necessary work for the common and uncommon neurological disease.
• The residents will participate in grand rounds at the North Shore University Health System on Tuesday mornings.

Residents will be at Glenbrook during the week, except for Tuesdays where they will be at Evanston. The above listed schedule shows the assigned clinics that the residents will be expected to attend. Within each half day, except Tuesdays, there are two listed clinics. The resident will attend the first listed and if unavailable will be assigned to the second listed clinic for that day. On Tuesdays, the resident will be expected to attend grand rounds at Evanston Hospital at 8am in Frank Auditorium and will then be responsible for performing lumbar punctures in the LP clinic on Tuesday mornings. The LP clinic will be run by the resident and the physician assistant and will be staffed with the attending. In the afternoon on Tuesday, the resident will be expected to evaluate patients in the neurology urgent care clinic.

Residents are expected to be at their assigned clinic from 8:00am-5:00pm each day. While at Glenbrook, they will have a patient scheduled for them each day from 9:00am-10:30am and 2:00pm-3:30pm in the corresponding subspecialty clinic. Residents are expected to attend their continuity clinic at University of Chicago and will be excused at those times.

Core Competencies

Core competency-based goals for this rotation for PGY-II residents are as follows:

Patient Care

• Perform a thorough history and physical examination, with a focus on aspects pertinent to patient's specific disorder in the full spectrum of neurological diseases.
• Demonstrate an understanding of the pathophysiology of cranial, spinal, peripheral nerve, pain, as well as behavioral disorders.
• Further learn the indications for ordering diagnostic imaging and electrophysiological studies such as CT, MRI, EEG, EMG/NCV, SSEP, BAERs, neuropsychological testing, interventional pain procedures, and LPs.
• Develop competence in reading and interpreting radiological studies such as MRI, CT, plain radiography, EEG, EMG/NCV and neuropsychological testing.
• Participate and provide leadership patient care and follow-up in the outpatient clinic.

Medical Knowledge

• Develop the ability to follow and care for a specified group of patients.
• Develop the ability to evaluate new patients and present to neurology faculty.
• Develop familiarity with the technical aspect of performing EMG, EEG, nerve conduction studies, interventional pain procedures, and lumbar punctures.
• Develop a knowledge base about the basic pathology of all types of neurology patients specifically Multiple Sclerosis, movement disorders, epilepsy, cognitive, pain, and sleep patients.

Practice Based Learning

• Understand the current medical literature and evidence-based medicine in the treatment of neurological patients.
• Lead in the literature search for question that may arise regarding patient care.
• Participate in teaching of medical students as the opportunities present themselves and present patient in a succinct and organized fashion.

Interpersonal and Communication Skills

• Establish a healthy doctor - patient relationship with patients and their families.
• Work effectively with other members of the medical team: doctors, residents, nurses, and allied health personnel.
• Maintain timely, comprehensive, accurate, and legible medical records.
• Understand the importance of keeping referring physicians apprised of the status of their patients.
• Identify any concerns with the health of fellow residents, staff, or allied health personnel.

Professionalism

• Provide compassionate patient care and maintain moral and ethical standards.
• Demonstrate sensitivity to patient's religion, culture, race, age, and gender, disabilities, and sexual orientation.
• Adhere to patient confidentiality and scientific integrity.
• Identify deficiencies in self or peer performance and suggest strategies for improvement.
• Understand professional and personal limitations.
• Be accountable for decisions and actions.
• Provide team leadership and set a standard of excellence to be emulated by junior level residents and medical students.

Systems Based Practice

• Improve throughput in both the outpatient and inpatient settings.
• Understand optimal use of information technology.

Overview

The general neurology consultation service rotation at North Shore University HealthSystem takes place during the PGY-III year at Evanston hospital for two one month rotations. The Consult Service covers all of the adult inpatient units including Medicine, Surgery, medical/surgical ICUs, OB-GYN, and Psychiatry.  The resident will rotate on this service Monday through Friday from 8:00am to 5:00pm. The Neurology resident will be the first to evaluate patients as requested by the various services. The resident then rounds with the attending on the consultation service at an agreed upon time each day. Patients will be followed up as needed..

Core Competencies

PGY-III residents spend two one month rotations on the consult service. When a PGY-III resident is assigned to the consult rotation early in the year, the PGY-III will work under the direction of a physician assistant (PA) also assigned to the service. The PGY-III resident will manage the service including the PA and medical students later in the year upon their return to the service after having had several months of exposure to inpatient neurology with close supervision.
Core competency-based goals for this rotation for PGY-III residents are as follows:

Patient Care

• During this rotation, competence in patient care is developed and demonstrated in the bedside evaluation of patients, in oral case presentations, and in written communications in the patients' chart. The Physician Assistant provides assistance, guidance, support, and supervision to the PGY-III resident early in the year. The supervising attending will evaluate resident competence in verbal and written presentations. Clinical skills include the ability to perform a complete history and physical examination, generate a rational differential diagnosis, formulate workup and management plans, and interpret results of studies in the context of patient care.

Medical Knowledge

• The resident is expected to develop a detailed body of knowledge related to neurological disorders that arise in the hospitalized general medical and surgical population. Medical knowledge is obtained through independent reading of the literature, reading in a patient-specific fashion, and through patient evaluations. The resident is also expected to apply knowledge from evidence-based medicine to patient care. Knowledge is also gained through didactic teaching. During this rotation, the PGY-III residents are expected to impart basic knowledge of neurology to rotating medical students.

Interpersonal and Communication Skills

• The resident will present patients to the supervising attending succinctly and completely and will maintain comprehensive, timely, and legible medical records. The resident will also communicate findings and recommendations to the requesting service in a clear fashion. The resident will communicate effectively with patients, families, and other health professionals. The resident will work as a member of a multidisciplinary team to maximize the care of complex medically ill patients. The resident will teach basic neurology to the rotating medical students.

Practice-Based Learning and Improvement

• The resident will develop the ability to investigate and evaluate his/her care of patients, to appraise scientific evidence, and to improve patient care based on constant self-evaluation and life-long learning. The supervising attending will ensure that the resident identifies strengths and deficiencies in his/her knowledge and implements changes leading to improvement. The resident will locate and use evidence from scientific studies in his/her care of patients. The resident will educate patients and their families about the patient's condition.

Professionalism

• Neurology residents will behave in a professional manner at all times. The highest standards of professionalism must be maintained, especially in interactions with patients, families, or other physicians. The resident will be responsible for tracking duty hours and reporting them to the education coordinator and program director. The resident should accomplish all assigned tasks related to clinical patient care within the limitations of the ACGME duty hour regulations. Chart notes must be completed in a timely fashion. Competence in professionalism will be assessed by supervising attendings.

Systems-Based Practice

• The resident will learn the constraints of acting as a consultant as opposed to being the primary service in providing patient care. The resident will also learn to work as part of a team to enhance patient safety and improve patient care quality. The resident will be able to complete the necessary workup, coordinate neurological care to the outpatient setting, and will develop appropriate billing skills.

Goals & Educational Objectives

• To expose residents to the broad array of acute and chronic neurological disorders that arise in the hospitalized general medical/surgical population.
• To learn to interact and communicate effectively with colleagues in other medical disciplines.
• To evaluate patients referred by another clinical service as soon as possible and provide feedback on diagnosis and recommended work-up in a timely fashion.
• To aid in educating other housestaff and medical students with respect to neurological diseases.
• To learn to function as a consultant rather than the primary service.

Responsibilities

• The Consult resident will be responsible for all consults requested by other services, the ER and medical/surgical ICUs from 8:00am to 5:00pm. Between 5:00pm and 8:00am on weekdays and throughout the weekend, the service attending will be responsible for covering staffed consults and evaluating new consults.
  • PGY-III:  Attend four days per week on the consult service.  Manage patients on the service (initially with the support of the service PA and then taking over management of the service after the first two weeks), review cases seen by the medical students and provide feedback to them, staff patients seen by you with the attending on service, and covering the EMU patients from 2:00pm to 6:00pm when there is not a PGY-IV on that service (this involves carrying the pager to deal with management issues as they develop while the patients are in the unit).
• The neurology resident will supervise medical students and non-neurology resident rotators in their evaluations of patients initially under the supervision of the PA and later independently.
• All consults must be staffed with an attending within a 24-hour period.
• The consult service will round on follow-up patients as necessary.
• The consult team will round daily with the Consult attending at an agreed upon time.

Assessment

• The resident will be given a verbal assessment of their accomplishment of the core competencies at the end of the rotation by the attending working with them in clinic.
• The resident will be evaluated with a formal written evaluation of their performance of the core competencies at the conclusion of the rotation.

Overview

Residents are expected to be at their assigned elective site from 8:00am to 5:00pm each day. Residents are expected to attend their weekly continuity clinic at University of Chicago and will be excused at those times.

Core Competencies

Patient Care

• Perform a thorough history and physical examination, with a focus on aspects pertinent to patient's specific disorder in the full spectrum of neurological diseases.
• Demonstrate an understanding of the pathophysiology of disorders, specific to the specialty area the resident is working in.
• Further learn the indications for ordering diagnostic imaging and electrophysiological studies such as CT, MRI, EEG, EMG/NCV, SSEP, BAERs, neuropsychological testing, interventional pain procedures, and LPs.
• Develop competence in reading and interpreting radiological studies such as MRI, CT, plain radiography, EEG, EMG/NCV and neuropsychological testing, as appropriate to the specific subspecialty.
• Participate and provide leadership patient care and follow-up in the inpatient/outpatient clinic.

Medical Knowledge

• Develop the ability to follow and care for a specified group of patients.
• Develop the ability to evaluate new patients and present to neurology faculty.
• Develop familiarity with the technical aspect of performing EMG, EEG, nerve conduction studies, interventional pain procedures, and lumbar punctures, as required by the specific subspecialty.
• Develop a knowledge base about the basic pathology of all types of neurology patients seen by the specialty clinic.

Interpersonal and Communication Skills:Practice-Based Learning and Improvement

• Establish a healthy doctor - patient relationship with patients and their families.
• Work effectively with other members of the medical team: doctors, residents, nurses, and allied health personnel.
• Maintain timely, comprehensive, accurate, and legible medical records.
• Understand the importance of keeping referring physicians apprised of the status of their patients.
• Identify any concerns with the health of fellow residents, staff, or allied health personnel.
• Understand the current medical literature and evidence-based medicine in the treatment of neurological patients.
• Lead in the literature search for question that may arise regarding patient care.
• Participate in teaching of medical students as the opportunities present themselves and present patient in a succinct and organized fashion.

Professionalism

• Provide compassionate patient care and maintain moral and ethical standards.
• Demonstrate sensitivity to patient's religion, culture, race, age, and gender, disabilities, and sexual orientation.
• Adhere to patient confidentiality and scientific integrity.
• Identify deficiencies in self or peer performance and suggest strategies for improvement.
• Understand professional and personal limitations.
• Be accountable for decisions and actions.
• Provide team leadership and set a standard of excellence to be emulated by junior level residents and medical students.

Systems-Based Practice

• Improve throughput in both the outpatient and inpatient settings.
• Understand optimal use of information technology.

Assessment

• The resident will be given a verbal assessment of their accomplishment of the core competencies at the end of the rotation by the attending working with them in clinic.
• The resident will be evaluated with a formal written evaluation of their performance of the core competencies at the conclusion of the rotation.

Description of the Rotation

The PGY-IV neurology resident rotation will be an elective based rotation located at any one of our NorthShore sites (Evanston, Highland Park, Skokie or Glenbrook campuses) where the resident may choose to work with the NorthShore neurologists amongst a list of specialties. The resident will be involved in outpatient and/or neurology specialty clinics depending on the specialty chosen. The resident will choose an elective for either two or four consecutive weeks (for a total of eight weeks in the PGY-IV year) and will see patient that will be scheduled specifically for the resident and will be staffed by the appropriate staff for that subspecialty. The resident will be responsible for evaluating the patient and developing diagnostic and therapeutic management plans for these patients in collaboration with the attending. The rest of the time, outside of the booked resident patient, the resident will be expected to observe and participate in the attending's clinic.

The rotating resident will be expected to do the following:

• The rotating resident participates in the provision of outpatient care particular to the subspecialty clinic in which they chose to be assigned.
  • Attend four days a week on your subspecialty elective. We request that you inform us of your subspecialty choices at least six months before you clinic dates so we can arrange a well rounded experience for you. The sooner you inform us of your requests the greater the likelihood you will be assigned the electives of your choice (if more than one resident is scheduled for the same two weeks the first to request a subspecialty area will get the assignment). You will be assigned both inpatient and outpatient duties as determined by the program director for that specialty area. You will also be expected to do some research on a topic related to the subspecialty area you are assigned to present to the program director and staff as determined by you and that attending. If you are assigned to the EMU for your elective you will be expected to manage the EMU patients and carry the EMU pager from 8:00am to 6:00pm in place of passing it to the PGY-II resident.
• The rotating resident will expand their knowledge base on the full spectrum of both general and sub-specialty neurological diseases.
• The rotating resident will learn to broaden their differentials diagnosis based on patient's presenting symptoms. The resident will also learn the necessary work-up for common and uncommon neurological diseases.
• The resident will participate in grand rounds at the NorthShore University Health System at the Evanston campus on Tuesday mornings.

Elective Options

• General Neurology
• Consult Service (either Glenbrook, or Highland Park and Skokie)
• Neuro-Immunology
• Neuro-Ophthalmology
• Movement Disorders
• Neuromuscular
• Sleep Medicine
• Pain Medicine
• Epilepsy including EMU
• Cognitive Neurology including Traumatic Brain Injury Clinic

Our program provides:

• 2 weeks of elective time during the PGY2 year
• 6 weeks of elective time during the PGY3 year
• 10 weeks of elective time during the PGY4 year

Elective time can be used for clinical work or research. The choice of elective must be approved by the Program Director. Additionally, PGY4 residents have eight weeks of elective/selective at North Shore which can be used to focus on subspecialty areas of their choice.

Elective time is requested by completing a Request for Neurology Elective. This form must be completed by the Resident, signed by the Program Director, and turned in to the Education Administrator. A supply of these forms can be obtained from the Education Administrator. This written request should include a description of what the resident will be performing/studying, who will be supervising this period of study, contact information, and, if the elective is an outside elective, the reason why an outside site is being chosen over The UCMC (i.e. neuro-ophthalmology, neuropsychiatry).

The Education Administrator oversees the administration of these electives, which includes obtaining an evaluation of performance during the elective by the faculty member(s) who supervised the resident. A letter and evaluation form will be sent to the supervising faculty member to be completed and placed in the resident’s file at the end of the elective.

Though some flexibility can be extended to the residents with regard to the use of their electives, these training module(s) were never intended to be used for additional time off from training. The Biological Sciences Division has allocated four weeks of vacation time for each resident per year. Due to federal reimbursement policies for medical schools, we must adhere to this policy and we must be able to account for the whereabouts of our residents at all times during their training. Any additional time off taken by a resident, aside from the four weeks of vacation time allotted to them, must (at the discretion of the Program Director and the Neurology faculty) be made up prior to graduation. This could delay graduation date. An example of this is maternity leave. Though a resident is granted four weeks of maternity leave in addition to any vacation time she has saved, there must be a determination by the Program Director and any other involved faculty as to whether that resident must make up that gap in her training. Any additional unaccounted for absences from the training program could result in loss of pay in addition to having to make up the time taken.

Residents are allowed four weeks of vacation each year. Vacation time is scheduled at the beginning of each year. Prior to beginning vacation time each resident must do the following:

• Notify the clinic at least one month in advance so that patients can be rescheduled.
• Arrange for coverage by another resident while you are on vacation.
• Sign out your pager to the covering resident.
• Change your voicemail message to notify callers that you will be away from the hospital. Make sure that the covering resident checks your voicemail daily (you must give the covering resident your voicemail passcode).
• Create an out-of-the-office email message notifying anyone sending you an email message that you will be away from the hospital.

ALL residents MUST be available to participate in the Residency In-Service Training Examination regardless of scheduled vacation/elective time.

ALL residents MUST be available to participate in the annual Barry G.W. Arnason Resident Research Symposium regardless of scheduled vacation/elective time. This symposium is held on the first Saturday in June.