hospital ward rotations i and ii - residency · web vieweach service has a team that may include a...

West Jefferson and MCLNOCurriculum

Description of Rotation

The neurology hospital rotation conforms to the mandated 18-months of primary patient care for patients with disease of the nervous system. It involves the PGY2 year the junior level and the PGY 2 and PGY4 year at the senior, supervising level.

The goal of the one month Neurology rotation is to expose the resident to a broad range of acute and chronic neurological disorders on either the General Neurology Service or the Stroke Service, in a tertiary care hospital setting. The individual teams are responsible for primary patients as well as consultations from other services in the hospital including the Emergency Department. The Stroke Service is responsible for acute and critical stroke management.

Educational Purpose

1. To provide an experience that will allow the resident to achieve basic competencies in the assessment and management of acute and chronic neurological diseases of the central and /or peripheral nervous system requiring hospitalization.

2. To provide an experience that will allow the resident to achieve basic competencies in performing consultations regarding acute neurological symptoms occurring as a complication of other disease states.

3. To learn the indications for ordering and to interpret ancillary and laboratory studies including neuroimaging, neurosonology, lumbar puncture, EEG and EMG.

4. To provide training and supervision that allows development of attributes of professionalism necessary to become an effective physician, including honesty, communication, proper interaction with patient, peers and ancillary staff, and proper referral of patients to provide appropriate provisions of care.

Assessment Summary

Resident performance will be assessed in the six core competencies:1. Patient Care (PC)2. Medical Knowledge (MK)3. Interpersonal and Communication Skills (ICS)4. Practice Based Learning and Improvement (PBLI)5. Professionalism (P)6. Systems Based Practice (SBP)

By the end of the rotation, the resident should receive and/or complete the following assessments

1. Verbal feedback from preceptors2. Global written assessments

Expectaions

During the rotation, the resident will work with a Staff Neurologist who will cover the service for a 2 week block. A senior Neurology resident will remain as the supervising resident for the entire module.

The resident is responsible for the initial evaluation of the admission or consultation as well as the formulation of differential diagnosis and initial management plan. The resident will be expected to present to the Staff that same day or the following morning. Each patient will be followed daily with a completed note in the chart until the patient is discharged or until the consultation is signed off.

Residents are responsible for pre-rounding on new and follow-up patients prior to meeting with the Staff . The Staff will round in the later part of the afternoon to staff new consults or admissions that had been received that day. Rounding will again conclude by 4:00 pm.

Call is beeper call no more than every fourth night for junior residents on each team. Call begins at 5 pm on the weekdays and 8 am on the weekends and ends at 8 am the following morning. There is back up from a senior Neurology resident.

Neurology strictly adheres to the duty hour limits as proposed by the ACME:1. Duty hours must be limited to 80 hours per week, averaged over a four-week

period. 2. Residents are provided with 1 day in 7 free from all educational and clinical

responsibilities. 3. A 10-hour time period is provided between all daily duty periods and after in-

house call.4. Continuous call must not exceed 24 hours, with an additional six hours

allowed for rounds, transfer of care and educational activities. Orientation

The orientation occurs on Day 1 of the rotation by the supervising resident on the service. A handout is provided to them. They will be contacted at least one day prior to the start of the service in order to receive their patient list and to receive a verbal handoff of patient care during the change of modules.

Supervision

Each Service has a team that may include a senior Neurology resident, 1-2 junior Neurology residents or Pediatric Neurology Fellow, and 1-3 rotators (Internal Medicine PGY 1 or 2, Psychiatry PGY 1, )

The Neurology attending physician will supervise all residents during the rotation. Residents have the primary responsibility and autonomy in performing the initial consultation evaluation and securing the results for all test ordered including imaging studies.

Mix of Diseases

Residents will meet the goals and objectives of the rotation through the identification, diagnosis, appropriate testing, management, and treatment of the following broad categories of neurological diseases:

A. Cerebrovascular diseaseB. Demyelinating diseaseC. Disorders of balance and dizzinessD. Disorders of higher cognitive function and communication (the dementias and

aphasias)E. Movement disorders including both the hyper and hyokinesiasF. States of altered consciousnessG. HeadacheH. Spinal disorders and pain (neck and low back)I. Neoplasms of the central nervous systemJ. Disorders of muscle and the neuromuscular junction K. Disorders of peripheral nerveL. EpilepsyM. Central nervous system infectionsN. Nutritional diseases of the nervous system

Patient Characteristics

Patients will be admitted to the Medicine Service. Consults will be received from all specialties serving each institution where the rotation takes place. Hospitalized patients requiring neurological consultations have either developed acute neurological symptoms during their hospitalization or have chronic neurological symptoms or disorders requiring further investigation or treatment. Adult patients above the age of 18, of various ethnic backgrounds and socioeconomic backgrounds with acute and chronic neurological disorders will be encountered during the rotation.

Procedural Skill Acquisition

Neurological skills include perfecting the technique of careful history taking as it applied to the neurological patient as well as the application of carefully done neurological examination. In addition, numerous opportunities to perform lumbar puncture for spinal fluid analysis are available for the trainee to perfect his/her skills. Finally, acquiring

knowledge interpretive skills and familiarity with neuroradiological studies such as CT scans, MRI studies, etc.

Conferences:The hospital clinic rotation is associated with numerous clinical conferences directed at patient management the treatment of neurological emergencies, and general didactic reviews. These conferences are delineated in the monthly lecture schedule that you receive via email. You should be aware that at certain institutions there are conference that are held at that rotation. You will also be made aware of these prior to your rotation again via email.

Resources: AAN Patient Care & Practice Management: http://www.aan.com/professionals/patient/index.cfmAAN Practice Guidelines: http://www.aan.com/professionals/practice/index.cfm Journal of the American Academy of Neurology: http://www.neurology.orgUp-to-Date

Reading List General Texts

Adams and Victor. Principles of Neurology McGraw Hill Bradley, Daroff, et al. Neurology in Clinical Practice. Butterworth Heinemann Rowland. Merritt’s Textbook of Neurology. Lea and Febiger (Available in H61

Atrium Patton. Neurological Differential Diagnosis (Available in H61 Atrium) Aminoff. Neurology and General Medicine. Churchill Livingstone Plum and Posner. The Diagnosis of Stupor and Coma. F.A.Davis Brazis, Masdeu and Biller. Localization in Clinical Neurology.. Little, Brown and

Co DeJong. The Neurological Examination. Harper and Row Gilman and Newman. Manter and Gatz’s Essentials of Clinical Neuroanatomy

andNeurophysiology. F.A.Davis

Appropriate journals and literature articles (Neurology, Archives of Neurology, Annals of Neurology) are continually referenced. Finally, many other germane neurological reviews and references can be found in the medical literature (Annals of Internal Medicine, Archives of Internal Medicine, American Journal of Medicine) and ophthalmological literature (Archives of Ophthalmology, American Journal of Ophthalmology).

http://www.neurology.org/

http://www.aan.com/professionals/practice/index.cfm

http://www.aan.com/professionals/patient/index.cfm

SUB-SPECIALTY: NeurologyROTATION EXPERIENCE: Inpatient Neurology Service

PATIENT CAREInpatient Neurology Service (PGY2) Patient CareObjectives Teaching Methods Assessment Strategy

Gather essential and accurate information about hospitalized patients with acute neurological symptoms including neurological emergencies (coma, mental status change, stroke, and seizure)

Direct Patient CarePerformance FeedbackClinical case conference

Global ratings Focused Record Review

Gather essential and accurate information about hospitalized patients with chronic neurological conditions/neurodegenerative disorders and common neurological problems, including headache, dizziness, and spine pain.

Direct Patient CarePerformance FeedbackClinical Case Conference

Global ratings Focused Record Review

Perform a extensive neurological examination and to be able to summarize their findings and localize the lesion in the central or peripheral nervous system

Clinical TeachingClinical ExperiencePerformance FeedbackClinical Case Conference

Global ratings

Formulate a differential diagnosis and management plan based upon their neurological assessment

Clinical TeachingDirect Patient CareClinical Case Conference

Global ratingsFocused record review

Identify and describe abnormalities seen in common neurological disorders on radiographic testing

Clinical TeachingPerformance FeedbackRadiology Conference

Global rating of live performance

Demonstrate technical skills in performing lumbar punctures Review of LP learning moduleStaff and resident instruction and supervision

Global rating of live performanceSelf and peer assessmentCase Logs

PATIENT CAREInpatient Neurology Service (PGY 3 and 4) Patient CareObjectives Teaching Methods Assessment Strategy

To become proficient in managing hospitalized patients with acute neurological symptoms including neurological emergencies (coma, mental status change, stroke, and seizure)


Global ratings Focused record review

To become proficient in managing hospitalized patients with chronic neurological conditions/neurodegenerative disorders and common neurological problems, including headache, dizziness, and spine pain.



Make informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence and clinical judgment



Develop supervisory skills regarding senior resident responsibilities on the ward, including organization of on-call schedules, fair distribution of workloads and supervision of junior residents


Global ratings 360 degree evaluation

Screen patients for acute stroke therapies quickly and accurately and initiate thrombolytic therapy in the appropriate setting based upon the history, NIH stroke scale and neuroimaging findings.

Direct Patient Care Performance Feedback

Global ratings NIH stroke scale online test

Perform comprehensive assessment consultations Direct Patient care Performance Feedback

Global ratings Performance feedback

MEDICAL KNOWLEDGEInpatient Neurology Service (PGY 2) Medical KnowledgeObjectives Teaching Methods Assessment StrategyCompare and contrast the medical and surgical approaches to treatment of ischemic stroke and explain the conditions under which each would be most efficacious

Review of evidence based guidelines and practice parameters proposed by the AANClinical teaching Departmental Conferences

Global ratings In-training examinationNIH stroke scale online test

Demonstrate the approach to assessing an acute change in mental status/coma and distinguish between different etiologies such as metabolic, toxic, infections, or vascular

Reading listClinical roundsDepartmental conferences

Global ratings In-training examinationFocused record review

Describe the underlying pathophysiology, diagnostic criteria and common treatment protocols for migraine

Review of evidence based guidelines and practice parameters proposed by the AANDidactic lectures

Global ratings In-training examination

Understand the uses and risks of anticonvulsant drugs in the treatment of acute and chronic epilepsy



Demonstrate and analytical thinking approach to a patient presenting with acute weakness in order to distinguish whether the lesion can be attributable to the central nervous system (brain or spinal cord) or peripheral nervous system (nerve root, peripheral nerve, neuromuscular junction or muscle) based upon assessment of upper or lower motor neuron signs.

Review of neuroanatomyClinical teaching


Demonstrate knowledge of relevant neuroanatomy and underlying pathology found in multiple sclerosis, Alzheimer’s dementia, Parkinson’s disease and cerebrovascular disease

Review of neuroanatomyDepartmental conferencesPathology lectures and brain cutting conference


MEDICAL KNOWLEDGEInpatient Neurology Service (PGY 3 and 4) Medical KnowledgeObjectives Teaching Methods Assessment StrategyDescribe the underlying pathophysiology, presenting signs and symptoms and common treatment protocols for acute and non-acute stroke


Global ratings NIH stroke scale online testNEX exam

Demonstrate an investigatory and analytic thinking approach to a patient with new onset seizure



Critically evaluate and judiciously apply the latest knowledge to the care of patients



Develop an approach to investigating and verifying new knowledge needed to care for patients



Describe the foundational principles and management of acute status epilepticus

Review of evidence based guidelines and practice parameters proposed by the AANClinical teaching


INTERPERSONAL AND COMMUNICATIONInpatient Neurology Service (PGY 2) Interpersonal and CommunicationObjectives Teaching Methods Assessment StrategyDemonstrate the ability to obtain, interpret and evaluate consultations from other medical specialties and to provide consultants with a diagnostic and management plan

Clinical roundsModeling

Global ratings

Provide patients and their families explanations of neurological disorders and treatment that is geared to their educational level, as well as respecting the patient’s cultural, ethnic, religious and economic backgrounds

Direct patient careModeling

Global rating Patient surveys

Work collaboratively with the multidisciplinary team involved in the inpatient care of neurological patients

Clinical roundsModeling

Global ratings Self and Peer assessments

Demonstrate effective communication within the team, with regards to patient’s current or change in neurologic status, anticipated problem, therapeutic regimen and diagnostic tests to be reviewed

Clinical roundsSign-out rounds

Self and Peer assessments

Inpatient Neurology Service (PGY3 and 4) Interpersonal and CommunicationObjectives Teaching Methods Assessment StrategyClearly describe a diagnostic and/or a therapeutic plan to a patient and family

Clinical RoundsDirect patient care

Global ratings 360 degree evaluations

Teach junior residents and medical students effectively Clinical RoundsDirect patient careModeling


Provide distressing news to patients and families clearly and compassionately


Global ratings

Develop effective strategies for interacting with “stressed” or angry patients and or families


Global ratings

Listen and evaluate the contributions of other members of the healthcare team

Clinical RoundsDirect patient careModeling


PRACTICE BASED LEARNING AND IMPROVEMENTInpatient Neurology Service (PGY2) Practice Based Learning and ImprovementObjectives Teaching Methods Assessment StrategyResearch clinical questions regarding their patient’s health problems using information technology to access on-line medical information to support their own education and to improve patient care and education

Electronic medical recordMedline/OVID searches- patient centered Case presentations

Self assessmentGlobal ratings

Evaluate the clinical literature applying knowledge of epidemiology, biostatistics, and research study design

Teaching conferences including Grand RoundsJournal Clubs

Global ratings of Journal club performance

Facilitate the learning of medical students Role ModelingOral presentationsPatient Centered instruction

Peer Assessments

Inpatient Neurology Service (PGY 3 and 4) Practice Based Learning and ImprovementObjectives Teaching Methods Assessment StrategyUse appropriate computer databases and online educational materials to assist in “real time” medical decision making


Self assessmentGlobal ratings

Apply knowledge of study designs and statistical methods to the appraisal of clinical studies and other information on diagnostic and therapeutic effectiveness

Teaching conferences including Grand RoundsJournal Clubs

Global ratings of Journal club performance Evaluations of Grand Rounds presentation

Facilitate the learning of junior neurology residents, medical interns, anesthesia interns and neurosurgery interns

Role ModelingOral presentationsPatient Centered instruction

Peer assessment 360 degree evaluations

Demonstrate and teach medical students to access medical information on their patient for record review as well as online information/medical databases to assist in their evaluations of patients


Global ratings

PROFESSIONALISMInpatient Neurology Service (PGY 2) ProfessionalismObjectives Teaching Methods Assessment StrategyInteract responsibly with patients, families and co-workers taking into consideration age, disability, culture and gender issues


Global ratings

Demonstrate appropriate use of the EMR in regards to patient respect and confidentiality

Direct patient care Modeling

Global ratings

Describe the differences of withdrawal of care, termination of care, and non-initiation of care and assist patients and their families in choosing these options in the appropriate clinical setting

Direct patient careModelingReview of Fast Facts learning modules

Global rating Self assessment

Inpatient Neurology Service (PGY 3 and 4) ProfessionalismObjectives Teaching Methods Assessment StrategyInteract responsibly with patients, families and co-workers taking into consideration age, disability, culture and gender issues


Global ratings

Demonstrate appropriate use of the EMR in regards to patient respect and confidentiality as well as understanding the scope and limits of patient confidentiality

Direct patient care Modeling

Global ratings

Discuss the differences of withdrawal of care, termination of care, and non-initiation of care and assist patients and their families in choosing these options in the appropriate clinical setting

Direct patient careModelingReview of Fast Facts learning modules

Global rating Self assessment

Understand the scope and limits of living wills and DNR status Direct patient careEthics conferences

Global ratings

Evaluate a patient’s capacity to make informed decisions and factors that would limit patient autonomy

Direct patient careEthics conference

Global ratings

SYSTEM BASED PRACTICEInpatient Neurology Service (PGY1 or 2) System Based PracticeObjectives Teaching Methods Assessment StrategyIdentification and performance of appropriate preventive care measures for the adult patient and the impact of preventive medicine on societal health-Stroke Risk Factor-Cerebrovascular and Cardiovascular Risk modification of stroke patients-Initiation of antiplatelet or antiocougulant therapy in stroke prevention

Direct patient careReview of evidence based medicine and guidelines of the AAN and Stroke AssociationDepartmental conferences including Cerebrovascualr conference/M&M

Global ratings Focused Record ReviewIn-training examination

Identification of psychosocial factors and their impact of care of progressive and disabling neurodegenerative disorders such as multiple sclerosis, Parkinson’s disease and Alzheimer’s disease and other dementias

Direct patient careClinical Rounds

Global ratings

Efficiently refer patients to appropriate allied health and social services to assist in acute care rehabilitation, long term management or home care assistance

Direct patient careModelingClinical rounds


Develop an understanding of cost-effective health care that does not impact quality of care

Role modelingClinical teaching Focused record review

Self assessmentFocused record review

Inpatient Neurology Service (PGY1 or 2) System Based PracticeObjectives Teaching Methods Assessment StrategyAdvocate for patients when dealing with resource allocation issues and complex payer systems problems

Direct patient careClinical teaching


Access quality allied health care and social services resources as they apply to patients with neurological disorders/disabilities

Direct patient careClinical teaching Rounds with case manager and SW


Practice high quality cost effective medical care across all practice venues



Understand how their patient care and professional practices affect other health professionals, organizations and society



hospital ward rotations i and ii - residency · web vieweach service has a team that may include a...

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