EDUCATIONAL PLAN NEUROLOGY RESIDENT ROTATION

Overview
The practice of neurology is grounded in the understanding and implementation of an accurate neurological examination.  Neurological complaints have been estimated in at least 20% if internal medicine primary care patients. This percentage may be higher in the geriatric age group. The internist will often be the first physician to see the patient with neurological findings. Accurate initial assessment can be critical to appropriate referrals and rapid intervention when warranted. The resident’s experience on the Neurology rotation will be oriented toward accurate assessment, differential diagnosis and first-line treatment options.

 

The rotation will include exposure to a variety of practice settings (inpatient and outpatient) as well as subspecialty, disease oriented clinics. The skills required will be gained on general hospital wards, designated neurological inpatient settings, intensive care units, general neurology ambulatory clinics and subspecialty, multidisciplinary ambulatory clinics. Didactic lectures on neurological subjects, small group teaching discussions associated with daily rounds and exposure to multidisciplinary team meetings will be available.  Additional opportunities are available for short-term research projects.
 
Training sites:
CRMC, Medical Office Buildings I and II @ CRMC, UCSF Fresno building and Sierra ambulatory clinic at UMC.

 

Responsible faculty:
Jeffrey Rosenfeld PhD, MD, FAAN  Chief, Division of Neurology
Tanya Warwick, MD,  Medical Director Stroke Program
Loveneet Singh, MD,  Medical Director Electrodiagnostic Lab
Loren Alving, MD
Lucian Maidan, MD

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Goals:

 

  1. Gain a solid foundation in the elements of an accurate and through neurological examination
  2. Gain experience in the diagnosis and management of:
    1. Seizure disorders
    2. Cerebrovascular accidents, hemorrhagic and nonhemorrhagic
    3. Neuromuscular disorders (nerve, muscle, neuromuscular junction)
    4. Movement disorders
    5. Coma and delirium
    6. Neurologic emergencies, including spinal cord compression, meningitis, and status epilepticus
    7. Neuropathies
    8. Diseases of the spinal cord
    9. Dementia
    10. Headache and facial pain
    11. Multiple sclerosis
    12. Myelopathies
    13. Cancer in the nervous system
    14. Radiculopathies
    15. The dizzy patient
    16. Nonspecific weakness and/or sensory loss

     

  3. Gain proficiency in performing lumbar punctures
  4. Understand the appropriate use of neurologic tests, including MRI, CT, EMG, nerve conduction testing, EEG, and examination of the spinal fluid

 

Learning objectives:

 

  1. Describe the classification of seizures.
  2. Describe the pharmacology of several different antiepileptic medications.
  3. Understand the risk factors, prevention and treatment of a stroke.
  4. Discuss indications and contraindications for thrombolytic therapy in acute stroke.
  5. Describe the characteristic features of Parkinson’s syndrome and Parkinson’s Disease.
  6. Demonstrate the proper examination and interpretation of the comatose patient.
  7. Describe the diagnostic elements of delirium and contrast with those of dementia.
  8. Describe the identifying features and common etiologies of peripheral neuropathy.
  9. Describe the appropriate work-up and interpretation of a peripheral neuropathy.
  10. Describe the history and physical examination findings expected in a patient presenting with spinal cord compression.
  11. List therapeutic options available in the treatment of migraine.
  12. Describe the classification of multiple sclerosis.
  13. Name several treatment options available to patients with multiple sclerosis
  14. Discuss the diagnostic approach to the dizzy patient.
  15. List common entrapment neuropathies and describe their physical findings.
  16. Describe the presentation, work-up and treatment of a patient with Gullian Barre Syndrome and several variants of GBS.
  17. Describe the presentation, work-up and treatment of a patient with Myasthenia Gravis
  18. Describe the presentation, work-up and treatment of a patient with Amyotrophic Lateral Sclerosis
  19. Appreciate the approach and management of patients with chronic, progressive neurodegenerative disease.
  20. Distinguish between upper and lower motor neuron clinical signs and symptoms
  21. Identify features on the neurological examination that distinguish psychogenic neurologic symptoms from neuropathological signs.
  22. Identify common infections in the nervous system and their treatments.
  23. Describe the indications for these neurodiagnostic services: EEG, EMG/NCS, SSEP, TCD

 


Weekly Schedule

UMC

 

 

Monday

Tuesday

Wednesday

Thursday

Friday

AM

New consults
f/u patients

Subspecialty clinic or Sierra Clinic

New consults
f/u patients

New consults
f/u patients

New consults
f/u patients

Noon

Medicine Grand Rounds

Noon Lecture

Noon Lecture

Noon Lecture or Neuro Grand Rounds

Noon Lecture

PM

Inpatient rounds

Subspecialty clinic

Inpatient rounds

Inpatient rounds or electrodiagnostic studies

Inpatient rounds



Expectations and responsibilities

  1. Participation in the inpatient Neurology consultation service.  Residents will be expected to evaluate and present new consultations and provide appropriate feedback (without prompting) on established patients.
  2. Timely attendance of all neurology clinics assigned for the rotation is expected.
  3. Residents should be available by pager during their neurology rotation.
  4. Clinic responsibilities.  Both new and follow-up patients will be seen in clinic.  The resident should perform a history and physical on the patients seen in clinic and present to the attending neurologist for that clinic.  The emphasis will be on accurate examination, initial localization, differential diagnosis and treatment options.  The progress note should contain all the elements of the case as outlined, and the attending’s participation should be noted by the resident.  The resident is responsible to see that laboratory and other tests ordered on the patient are followed up by chart check in the clinic.
  5. Inpatient consultations should be completed on the same day that they are received unless alternative arrangements are made with the Neurology attending on the service.
  6. Teaching sessions will be provided as formal didactic lectures, 1:1 tutorials and/or small group sessions. The resident may be asked to present a topic for discussion as well as to participate in talks provided by other residents on the service.  Attendance in these teaching sessions is required.
  7. Residents are expected to take initiative to read background information pertaining to the patients they see while on the neurology rotation and, as appropriate, patients of particular interest seen by others on the Neurology service.

 

References

 

The Neurology faculty and the medical library have access to multiple reference textbooks on Neurology (i.e. Roper, Merritt, Aminoff), specialty journals, and many other books on neurologic subject matter.  Upon request these materials will be available to any residents.  The resident assumes all responsibility for borrowed materials from the Neurology staff

 

INTEGRATION OF CORE COMPETENCY TRAINING IN THE NEUROLOGY ROTATION

 

PATIENT CARE
Efforts will be made to educate resident in Neurology by showing how to establish priorities in accurate information gathering, and by demonstrating methods of communication with patients and with other health care providers - particularly when acting as a consultant.  Educating residents on a thorough but efficient neurological exam and appropriate use of diagnostic studies, such as CT, MRI, EMG, EEG, and CSF laboratory tests will be accomplished on rounds as well as by lecture format.  Patient management planning will be practiced with emphasis on adaptability to information flow.

 

A PGY-1 resident would be expected to obtain focused and appropriate information, develop ability to analyze and integrate information to define the clinical problems, and outline principles of management of those clinical problems.  The resident learns to deal with difficult emotional, social, and psychological circumstances.

 

A PGY-2 resident would be expected to know what information is relevant and to be able to analyze and integrate the information.  Neurological problems should be clearly defined.  The major differential diagnoses and treatment options are expected.  Knowledge of some complications of treatment is also expected.  The senior resident also plays a supervisory role of the PGY-1.

 

A PGY-3 resident would be expected to fulfill the expectations for a PGY-2 resident as outlined, but should have a more sophisticated approach to differential diagnosis, by fully enumerating the likely vs. unlikely diagnostic possibilities and outlining a more focused approach to diagnosis.  The PGY-3 would be expected to balance the risks and benefits of diagnostic approaches and treatment options.

 

HOW TO MEASURE:
Supervision and feedback during attending rounds
End of rotation evaluations
Attendance at didactic conferences


           
MEDICAL KNOWLEDGE


Residents will gain medical knowledge by participation in the Neurology educational plan while rotating on the Neurology Service.   In addition, experience and learning about topics in Neurology will be ongoing on other services guided by knowledgeable faculty, chief and senior residents and other learned peers.   Reading of textbooks, journals and use of electronic media is encouraged and methods of life-long learning are presented whenever possible.

 

A PGY-1 resident would be expected to have basic medical knowledge and pathphysiological mechanisms of a neurological diseases, common laboratory tests, and basic understanding of pharmacology.

 

A PGY-2 resident would have above and knowledge in etiologies, risk factors, diagnosis, complications, and therapies of the major neurological diseases as well as indications and application of radiological imaging techniques.

 

A PGY-3 resident would have the above and also be conversant with the recent medical literature of these major diseases.

 

HOW TO MEASURE
Supervision and feedback during attending rounds
End of rotation evaluations
Attendance at didactic conferences
Scores on in-service exams
Scores on Board Exams

 

 

PRACTICE-BASED LEARNING AND IMPROVEMENT


Residents will improve skills in neurological history taking by emphasis on locating the deficit and establishing a time course for its onset and progression during case presentations.  Likewise, improvement in neurological examination skills will be stressed during bedside teaching activities.  Expansion of skill in formulating differential diagnosis for neurological illnesses will be practiced on rounds and stress will be placed on communication of Neurology consultant’s recommendations with referring physicians. Important literature and electronic information resources for Neurology will be defined and learning important parameters and pitfalls in Neurology articles will be included in the educational process.  Residents will be asked to keep a log of patient diagnoses as part of the methodology to assure that a broad experience in Neurology problems by the residents is acquired.

 

A PGY-1 resident is expected to learn how to search the medical literature to answer a clinical question.  He/she should learn how to read papers on therapy and diagnostic tests as well as meta-analyses.  He/she should be able to properly evaluate a randomized controlled trial published in the medical literature.  He/she should begin to prioritize best evidence for clinical practice.  He/she should seek reading material and read on a topic that applies to each of their patients.  He/she will demonstrate mastery of the electronic patient record and use of basic electronic media for pursuing clinical questions.

 

A PGY-2 resident would have mastered the above.  He/she would be able to consistently identify the type of study which could answer medical questions which arise, as well as analyze more sophisticated types of papers such as cost analyses and clinical decision analyses.  He/she should demonstrate a basic understanding of Baye’s theorem in the daily practice of Medicine.  He/she should be able to more fully integrate the patient’s unique circumstance and preferences in applying best evidence to medical practice.  In addition, he/she would demonstrate ability to self-evaluate, utilize feedback, and begin to initiate strategies for self-improvement.  He/she should also have started a pattern of study and self-reflection that will allow for life-long learning.

 

A PGY-3 resident would have achieved the above, and assess best evidence for medical practice for medical care, taking a more critical analytic approach to published practice guidelines and considered the generalisability of the information to his/her medical patient.  He/she should fully integrate the patient’s unique circumstances in applying best practices.  He/she would fully integrate life-long learning strategies, self evaluation, and improvement strategies into their practice of day-to-day Medicine.

 

HOW TO MEASURE

Supervision and feedback during attending rounds
End of rotation evaluations
Attendance at didactic conferences
Scores on in-service exams
Scores on Board Exams
Evaluation of patient care logs


           

INTERPERSONAL AND COMMUNICATION SKILLS


Patient interviewing and communication skills with special emphasis on Neurology will be developed in the residents in the Neurology clinics and inpatient settings.  Communication techniques with other members of the patient’s healthcare team – both physicians and other ancillary team members – will be practiced and modeled during the Neurology service rotation.  These will include oral as well as written modalities.  Development of effective working relationships with other team members will be fostered and expectation of the role of consultant specialist will be defined.

 

A PGY-1 would learn to develop these essential skills.

 

A PGY-2 should demonstrate possession of some of these skills.

 

A PGY-3 should routinely demonstrate these skills and serve as a role model for junior residents.

 

HOW TO MEASURE
Supervision and feedback during attending rounds
End of rotation evaluations
Evaluation of patient care logs
Review of patient care notes
Evaluations by peers (E-value)
Evaluations by nurses (E-value)

 

 

PROFESSIONALISM

 

Residents will be expected to master behavior which manifests compassion, respect and integrity.  A commitment to excellence and on-going professional development should be demonstrated.

 

A PGY-1 resident is expected to demonstrate punctuality, integrity, honesty, and respect forpeers and patients.

 

A PGY-2 resident is expected to demonstrate the above, as well as demonstrate the ability toteach and be a role model for the junior resident, displaying enthusiasm for knowledge acquisitionand self-improvement.

 

A PGY-3 resident is expected to demonstrate the above, as well as demonstrate a more fullydeveloped process for self-improvement and life-long learning.

 

HOW TO MEASURE
Supervision and feedback during attending rounds
End of rotation evaluations
Evaluations by peers (E-value)
Evaluations by nurses (E-value)

 

 

SYSTEMS-BASED PRACTICE


During the Neurology rotation, the specific support systems that are available to patients with neurological diseases will be delineated.  These will include outpatient, pharmacy, social and financial support services, as well as others.  The different services available in the various medical care systems in the community will be defined and opportunities for resident experience as many systems as possible will be made.  The practice of cost-effective evaluation and care of patients with neurological diseases will be included in training venues.  Residents will be encouraged and expected to participate in quality improvement activities and opportunities for involvement in such processes within the Community Medical Centers structure will be available.  Research methodology for assessment of quality improvement processes will be described.

 

A PGY-1 should learn to recognize and access different available resources for patient care and learning.

 

A PGY-2 should be able to fully mobilize outside resources in the care of the patient.  He/sheshould be able to describe and follow clinical pathways.  He/she should begin to work on systems improvement.

 

A PGY-3 should fully articulate appropriate clinical pathways and note appropriate exceptions to them.  He/she should have completed a systems improvement project as a member of a group.

 

HOW TO MEASURE 
Supervision and feedback during attending rounds
End of rotation evaluations
Evaluation of patient care logs
Review of patient care notes
Evaluations by nurses (e-value)
Documentation of system-based quality improvement project participation