Each hospital rotation has a site director who is responsible for the educational quality of the rotation, for assuring appropriate supervision of the clinical activities of residents during the rotation, for updating the rotation as appropriate and for coordinating the evaluations from that rotation.
A) PMH/ZLUH STROKE ROTATION:
Site director: Dr. Mark Johnson
Responsible faculty: Drs. Johnson and Graybeal and Warnack
Faculty responsibilities: To assume care of patients on service, supervise residents in their provision of care, instruct residents in knowledge and skills and professionalism, and provide regular feedback plus summative evaluations on residents
Educational rationale: This is a concentrated exposure to cerebrovascular medicine, under supervision of subspecialists. Learning is facilitated by daily interactions with related fields such as interventional radiology and PMR.
Service mission: To provide care in PMH and ZLUH for primary and consult patients with cerebrovascular diseases.
Duration of exposure: Four one-month rotations during PGY2-3 (junior resident) and 2 one-month-long rotation as PGY4 (senior resident)
Policies and Procedures: Daily attendance at noon-time lectures, duty hours policies, disciplinary policies and procedures are outlined in the residency handbook
Senior resident
Educational goals:
1. To supplement basic and clinical knowledge about cerebrovascular disease
2. To learn appropriate management of patients with stroke, based on individual circumstances
3. To learn to coordinate and supervise a clinical team
4. To practice educating junior residents and students about care of neurologic emergencies: stroke, subarachnoid and intracranial hemorrhage
Service responsibilities:
1. To ensure continuous and appropriate care of primary and consult patients on the service
2. To appropriately delegate responsibilities to juniors and students
3. To supervise and ensure hand-offs each day, and at change of service
4. To attend neuroradiology and nursing/attending rounds
Call:
1. In house 7 am through 5 pm Monday through Friday plus either Saturday or Sunday
2. In conjunction with General Service chief and ER senior, to split 24-7 second-call for PMH/ZLUH neurology from home. During overnight phone coverage, must discuss all admits and consults with juniors, and must personally evaluate patients needing special attention
3. One 24-hour period per week, to be arranged with attending and other senior resident(s), without any hospital responsibilities
Junior residents
Educational goals
1. To learn to identify localization, likely etiology, prognosis, appropriate investigation, and management, of common urgent neurologic in-patient issues, primarily cerebrovascular diseases
2. To become familiar with up-to-date clinical research data regarding risk factors and interventions for cerebrovascular disease
3. To learn appropriate role for speech, physical and occupational therapies, and patient selection for extended rehabilitation measures, home help and nursing home disposition
4. To educate assigned medical students in clinical and basic neurology
Service responsibilities
1. To write admit H/P, daily progress notes and dismissal summary on own patients. All hospitalized patients will be assigned to one or other of the junior residents. Usually each resident will have medical student(s), who may write notes; irrespective of this the resident should personally see every patient and write a SOAP note each day.
2. To order test and consults as appropriate, follow up on results, and communicate the information to the senior and attending
3. To perform H/P and follow-up on consults assigned by the seniors
4. To perform hand-off of his/her patients to the on-call resident, and sign-off at the end of the rotation
Call
1. 5 pm to 7 am q4 nights 7 days a week: covers ER calls, emergency consults at ZLUH and PMH, and outside calls during these hours
2. Resident on call provides after-hours cross-coverage of EMU and of general service primary and consult patients
3. Must discuss all ER and emergency consults with supervising resident or attending in first 2 months of taking call, and when such backup is desired thereafter
4. If at any time the assigned responsibilities exceed the resident?s ability to provide good patient care, the senior resident or attending should be called for help.
5. Four periods of 24-hour should be taken free of clinical responsibilities during the month
Transfer policy
1. During daytime hours, a PGY2-3 on each service will take direct and ER admissions.
2. After 5 pm, the on-call PGY2-3 on call will write admit H/P on all admissions
3. Patients whose diagnosis make them more appropriately cared for by the other service should be transferred at neuroradiology rounds the next morning.
Intern (when present during some months; usually neurosurgery or psychiatry)
The intern will be assigned to work with a PGY2-3 resident and assist the resident to meet their service responsibilities. The chief resident will equalize as much as possible the number of months during the year that each PGY 2/3 resident works with an intern
Educational goals
1. To learn to identify causes of acute neurologic emergencies, particularly cerebrovascular disease
2. To become familiar with use and interpretation of neuroimaging in this setting
3. To learn to appropriately use stroke medications and physical medical interventions
4. To improve knowledge of basic and clinical neurology
Service responsibilities
1. To collaborate professionally with the PGY2-3 resident assigned
2. To write admit H/P, daily follow up notes and dismissal summaries on assigned patients
3. To communicate with resident and other team members to optimize patient care
4. To attend neuroradiology and nursing-attending rounds, Grand Rounds, and Tuesday through Friday lunchtime conferences
Call
1. In house 6 days a week 7 am through 5 pm
2. Take overnight call with the assigned resident q4 nights
3. Four periods of 24-hour should be taken free of clinical responsibilities
B) PMH/ZLUH General Neurology service
Site director: Dr. Padraig O'Suilleabhain
Responsible faculty: Drs. O'Suilleabhain, Wolfe, Elliot, Frohman, Cannon, Womack, Rosenberg, Tansey, Van Ness, Diaz Arrastia, Agostini, Powell, Habib, Trivedi, Singer, Vernino, Nations.
Faculty responsibilities: To assume care of patients on service, supervise residents in their provision of care, instruct residents in knowledge and skills and professionalism, and provide regular feedback plus summative evaluations on residents
Educational rationale: This is a concentrated exposure to the broad range of acute neurological problems that present at a large multispecialty urban medical center.
Service mission: To provide care in PMH and ZLUH for primary and consult patients with neurological diseases. Most patients on this service will be consults with a smaller number of inpatients who have non-stroke problems (e.g. MS exacerbation, neuromuscular emergencies, seizures, encephalopathy, cord compression?).
Duration of exposure: Four one-month rotations during PGY2-3 (junior resident) and 2 one-month-long rotation as PGY4 (senior resident)
Policies and Procedures: Daily attendance at noon-time lectures, duty hours policies, disciplinary policies and procedures are outlined in the residency handbook
Senior resident
Educational goals
1. To increase knowledge of clinical neurology to the level of being able to independently care for patients
2. To practice supervision of a clinical service
3. To practice teaching junior residents and medical students, with particular emphasis on finding and communicating up-to-date clinical research data
Service responsibilities
1. To ensure continuous and appropriate care of primary and consult patients on the service
2. To appropriately delegate responsibilities to juniors and students
3. To supervise and ensure hand-offs each day, and at change of service
4. To attend neuroradiology and nursing and attending rounds.
5. To select patient for the Friday Rosenberg conference
Call
1. In house 7 am through 5 pm Monday through Friday plus either Saturday or Sunday
2. In conjunction with Stroke Service chief and ER senior, to split 24-7 second-call for PMH/ZLUH neurology, from home
3. During overnight phone coverage, must discuss admits and consults with juniors, and must personally evaluate patients needing special attention
4. One 24-hour period per week, to be arranged with attending and other senior(s), without any hospital responsibilities
Junior residents
Educational goals
1. To learn to take history and to examine patients with a variety of neurologic conditions including demyelinating, neuromuscular, and comatose patients
2. To become familiar with presentation and management of common neurologic diseases in hospitalized patients
3. To start to learn up-to-date clinical research data regarding prognosis and interventions for these conditions
4. To learn appropriate role for speech, physical and occupational therapies, and patient selection for extended rehabilitation measures, home help and nursing home disposition
5. To educate assigned medical students in clinical and basic neurology
Service responsibilities
1. To write admit H/P, daily progress notes and dismissal summary on own patients. All hospitalized patients will be assigned to one or other of the junnior residents. Usually each resident will have medical student(s), who may write notes; irrespective of this the resident should personally see every patient and write a SOAP note each day.
2. To order test and consults as appropriate, follow up on results, and communicate the information to the chief and attending
3. To perform H/P and follow-up on consults assigned by the service chief
4. To perform hand-off of his/her patients to the on-call resident, and sign-off at the end of the rotation
Call
1. 5 pm to 7 am q4 nights 7 days a week: covers ER calls, emergency consults at ZLUH and PMH, and outside calls during these hours
2. Resident on call provides after-hours cross-coverage of EMU and of general service primary and consult patients
3. Must discuss all ER and emergency consults with supervising resident or attending in first 2 months of taking call, and when such backup is desired thereafter
4. If at any time the assigned responsibilities exceed the resident?s ability to provide good patient care, the senior resident or attending should be called for help.
5. Four periods of 24-hour should be taken free of clinical responsibilities
Transfer policy
1. During daytime hours, a PGY2-3 on each service will take direct and ER admissions.
2. After 5 pm, the on-call PGY2-3 on call will write admit H/P on all admissions
3. Patients whose diagnosis make them more appropriately cared for by the other service should be transferred at neuroradiology rounds the next morning.
Intern (when present during most months, usually from psychiatry)
Most months, an intern will be assigned to assist one of the residents to meet their service responsibilities. The chief resident will equalize as much as possible the number of months during the year that each PGY2/3 resident has an intern
Educational goals
1. To learn to take an appropriate history and perform a neurologic exam in hospitalized patients
2. To become familiar with evaluation and management of acute demyelinating, neurooncologic and neuromuscular disease, and with coma
3. To become familiar with use and interpretation of lab investigations and neuroimaging in this setting
4. To learn to appropriately use neurologic medications and physical medical interventions
5. To improve knowledge of basic and clinical neurology
Service responsibilities
1. To collaborate professionally with the PGY2-3 resident assigned
2. To write admit H/P, follow up notes and dismissal summaries on assigned patients
3. To communicate with resident and other team members to optimize patient care
4. To attend neuroradiology and nursing-attending rounds, Grand Rounds, and Tuesday through Friday lunchtime conferences
Call
1. In house 6 days a week 7 am through 5 pm
2. Take overnight call with the resident q4 nights
3. Four periods of 24-hour should be taken free of clinical responsibilities
C) ER senior resident.
Site director: Dr. Mark Johnson
Responsible faculty: Drs. Johnson and Graybeal and Warnack
Faculty responsibilities: To be available to see or discuss as needed patients seen in ER by the assigned resident, and to review decisions as appropriate the decisions made by that senior resident.
Educational rationale: This allows the resident, in their final year before graduation to independence, to assume progressive responsibility for triage and decision making, seeing patients with undiagnosed and sometimes serious neurologic disease, in a busy urban ER.
Service mission: To perform initial evaluation on patients presenting to ER with neurologic problems, and to initiate management and admission if appropriate.
Duration of exposure: Two one-month rotations as PGY4.
Policies and Procedures: Daily attendance at noon-time lectures, duty hours policies, disciplinary policies and procedures are outlined in the residency handbook
Educational goals
1. To learn to triage, stabilize and dispose of patients presenting to ER with neurologic problems
2. To practice effective communication with other health professionals such as ER staff
3. To practice appropriate use of resources, e.g. urgent out-patient appointments versus referrals versus admissions
Service responsibilities
1. To evaluate ER consults during in-house hours listed below in the call paragraph. Disposition options are: dismiss without follow-up; dismiss with urgent follow up in that resident?s own continuity clinic; provide neurologic recommendations if a non-neurology service is admitting patients and then to either follow up personally or delegate a junior to consult on the patient as appropriate; admit to the stoke or general service
2. To take outside calls and to field consults from PMH (inpatient and outpatient) and ZLUH during call hours. Consults can be completed by the senior, or delegated to a junior on either service as appropriate
3. To perform urgent LPs as requested by other services
4. To attend neuroradiology rounds. Absence from rounds for urgent ER or in-house evaluations should be cleared with the attending
5. Cover own (reduced) continuity clinic once per week: no new patients, 3 regular returns, and 3 slots for the resident to see ER dismissals needing urgent follow-up
Call
1. In house 7 am through 5 pm Monday through Friday
2. In conjunction with Stroke and General service chiefs, to split 24-7 second-call for PMH/ZLUH neurology from home
3. During overnight phone coverage, must discuss admits and consults with juniors, and must personally evaluate patients needing special attention
D) Epilepsy monitoring unit
Site director: Dr. Paul Van Ness
Responsible faculty: Drs. Van Ness, Diaz Arrastia, Agostini.
Faculty responsibilities: To assume care of patients on service, supervise residents in their provision of care, instruct residents in knowledge and skills and professionalism, and provide regular feedback plus summative evaluations on residents
Educational rationale: This is a concentrated exposure to epilepsy, with a focus on evaluating and managing difficult cases. There is in addition exposure to EEG interpretation.
Service mission: To characterize seizure disorders and epileptic syndromes, and to identify the individualized optimal treatment plan.
Duration of exposure: Two one-month rotations during PGY2.
Policies and Procedures: Daily attendance at noon-time lectures, duty hours policies, disciplinary policies and procedures are outlined in the residency handbook
Educational goals
1. To learn the semiology of different seizure types and origins
2. To learn the risk factors and prognosis of epileptic syndromes
3. To learn appropriate use of medications, also drug side-effects and interactions
4. To become familiar with indications, process and outcome of epilepsy surgery
5. To observe EEG recording, to become familiar with EEG technical principles and common EEG waveforms: to read and write report of 10 EEGs for review by faculty
Service responsibilities
1. To admit patients upon arrival and obtain consent for Video EEG monitoring
2. To review new clinical events daily in preparation for rounds; round mid morning and attend team conference
3. To write daily progress notes, and pre-discharge orders and prescriptions the day before d/c
4. To dictate discharge summaries within 24 hours of discharge
Call
1. No overnight call
E) VA Medical Center
Site director: Dr. Greg Carter
Responsible faculty: Drs. Carter, Dashieff, Stuve and Haller.
Faculty responsibilities: To assume responsibility for the recommendations and actions of the service, to supervise residents in their provision of care, instruct residents in knowledge and skills and professionalism, and provide regular feedback plus summative evaluations on residents
Educational rationale: The VA rotation shows residents how to provide care within the VA system. Residents will also see neurological disease specific to this setting.
Service mission: To provide neurologic consultation to VA in-patients, and to provide outpatient care to VA patients with neurological diseases.
Duration of exposure: Two one-month rotations during PGY2-3 (junior resident) and two one-month-long rotation as PGY4 (senior resident)
Policies and Procedures: Daily attendance at noon-time lectures, duty hours policies, disciplinary policies and procedures are outlined in the residency handbook
Educational goals
1. To learn presentation, investigation and management of neurologic problems in hospitalized VA patients including stroke, coma, neuromuscular and dementing illnesses
2. To practice management of in the outpatient setting of chronic neurologic problems including headaches, movement disorders and epilepsy.
3. To refine knowledge of neurologic medications with particular emphasis of drug interactions
4. To continue to read basic and clinical neurology, including up-to-date clinical research data
Service responsibilities
1. To provide neurologic consultation on hospitalized and ER patients
2. To attend at least two of the VA out-patient clinics per week
Call
1. Expected to be on campus 8 am through 5 pm five days per week
2. Two residents should divide 24-7 phone coverage equitably
3. Each resident should have at least 4 days per month without any hospital responsibility
F) Child neurology
Site director: Dr. Rana Said
Responsible faculty: Drs. Said, Arnold, Iannacone, Dowling, Sparagana, Delgado
Faculty responsibilities: To assume responsibility for the recommendations and actions of the service, to supervise residents in their provision of care, instruct residents in knowledge and skills and professionalism, and provide regular feedback plus summative evaluations on residents.
Educational rationale: This is a concentrated exposure to the range of acute neurological problems affect children, as it is based at a large urban pediatric hospital. In addition, the rotation provides training general and subspecialty child neurology outpatient clinics.
Service mission: To provide care in CMC and TSRH for children with neurological disease.
Duration of exposure: Three one-month rotations during PGY3.
Policies and Procedures: Daily attendance at noon-time lectures, duty hours policies, disciplinary policies and procedures are outlined in the residency handbook
Educational goals
1. To practice taking pediatric history and performing age-appropriate examinations
2. To learn the presentations and management of the neurologic problems commonly seen in children
3. To learn the roles and use of investigations and medications in minors
4. To become familiar with normal physical, cognitive and behavioral development
5. To learn about perinatal complications, headaches, CNS infections, seizures and strokes in children
Service responsibilities
The 3 months child neurology is typically split into 2 months inpatient at CMC, and 1 month outpatient which is equally split between CMC and TSRH as follows:
am pm
Mon Sparagana Bankone clinic
Tue Sparagana/Motor Tuberous Scler/Delgado/Holopros
Wed Reading Delgado
Thur Iannaccone Sparagana
Fri Said Arnold
1. To write H/P and follow-up notes on consult patients in CMC
2. To effectively interact with other services and nursing and ancillary staff in providing patient care
3. To evaluate patients in outpatient clinics in CMC and TSRH
Call
1. Expected to be at the assigned hospital or clinic 8 am to 5 pm 5 days per week
2. One in three days provides overnight coverage from home, coming to evaluate ER or inpatients as necessary, and responding to parents phone queries
G) EMG/Neuromuscular disease
Site director: Dr. Gil Wolfe
Responsible faculty: Drs. Wolfe, Vernino, Trivedi, Nations, Struyk, Elliot
Faculty responsibilities: To supervise residents in their provision of care, to instruct residents in knowledge and skills particularly in the technical skills of NCS and EMG, as well as their professionalism, and provide regular feedback plus summative evaluations on residents
Educational rationale: The ability to perform and interpret EMG and NCS and EP is taught here, and the clinical utility of these procedures is taught, as well as the clinical management of neuromuscular diseases.
Service mission: To perform requested electrodiagnostic tests and to evaluate and manage neuromuscular diseases.
Duration of exposure: Two-month rotation during PGY3.
Policies and Procedures: Daily attendance at noon-time lectures, duty hours policies, disciplinary policies and procedures are outlined in the residency handbook
Educational goals
1. To learn basic electrophysiologic principles underlying EMG and nerve conduction studies
2. To learn to perform EMG and NCS under supervision of attendings and fellows
3. To become familiar with the presentation, evaluation, management and course of common neuromuscular problems including myopathies, neuropathies and junction disorders
4. To read the provided materials and display familiarity and understanding of it
Service responsibility
1. To attend the neuromuscular clinic and EMG lab, perform H/P and studies as directed by the attendings
H) Spinal-cord injury medicine at PMH/ZLUH (3 weeks) + general neurology at St Paul (1 week)
Site director: Dr. Keith Tansey
Responsible faculty: Drs. Tansey and Singer
Faculty responsibilities: To supervise residents in their provision of care, to instruct residents in knowledge and skills as well as their professionalism, and provide regular feedback plus summative evaluations on residents
Educational rationale: To provide a concentrated exposure and the associated education in the management of patients with SCI, under supervision of subspecialist. The week spent at SPUH provides a short exposure to neurologic medicine in the setting of a small private hospital system.
Service mission: To provide SCI medical recommendations.
Duration of exposure: One-month rotation during PGY2.
Policies and Procedures: Daily attendance at noon-time lectures, duty hours policies, disciplinary policies and procedures are outlined in the residency handbook
Educational Goals
1. To learn the fundamentals of the science and clinical practice of SCI medicine
2. To learn the roles of PMR, PT, OT, neurosurgery and related caregivers in SCI
3. To become familiar with selected topics in these areas through directed readings
4. To develop skills and acumen in providing inpatient neurology consult care
Service Goals
1. To assist the SCI Medicine service with acute and subacute SCI patient care
2. To round MWF afternoon with the SCI service
3. At SPUH: to provide timely neurologic consultation, and appropriate follow-up care.
4. At SPUH: to present patients on daily ward rounds to the attending neurologist.
Call
There are no call responsibilities while on SCI. During the week that the resident is assigned to St Paul, the resident carries the pager 24 hours per day from Monday 8am through Sunday 8am; the attending takes the calls from Sunday 8am through Monday 8am. To avoid fatigue and to comply with work hour rules, the resident must have no duties for 24 continuous hours, for example the Sunday day and night. Additionally, it is expected that the resident will receive no more than 1 outside-office-hours call on no more than 3 nights during the week: if this expectation is exceeded, the resident will inform the program director who will monitor calls and schedule closely, and make changes as needed.
I) Psychiatry consult-liaison service at ZLUH
Site director: Dr. Celia Jenkins
Responsible faculty: Drs. Jenkins and Queenan
Faculty responsibilities: To supervise residents in their provision of care, to instruct residents in knowledge and skills of psychiatry, as well as their professionalism, and provide regular feedback plus summative evaluations on residents
Educational rationale: A focused exposure to psychiatric care, under supervision of specialists, will increase the resident's ability to evaluate and manage their neurologic patients? psychological and psychiatric problems.
Service mission: To provide consultation recommendations for patients with psychiatric problems.
Duration of exposure: One-month rotation during PGY1 or PGY2
Policies and Procedures: Daily attendance at noon-time lectures, duty hours policies, disciplinary policies and procedures are outlined in the residency handbook
Educational goals
1. To learn to take a psychiatric history and elicit and interpret appropriate signs.
2. To learn the presenting signs, differential diagnoses, management, and prognoses of major psychiatric disorders.
3. To promote understanding of the interrelationships among psychosocial and biomedical factors in the general hospital setting.
4. To gain a basic understanding of psychopharmacology of the medically ill, including adverse drug effects and drug-drug interactions.
Service responsibilities
1. To attend the mandatory
2. To provide and document psychiatric evaluations and follow-up treatment of inpatients at Zale-Lipshy Hospital for whom psychiatric consultations have been requested.
Call
General schedule is Monday through Friday 8am-5pm. No weekend or night call for the service. Mandatory attendance at Monday consult conference (12noon-2pm) and attending rounds (times and days vary, usually 4 times/week). The only exception to conference attendance is if the resident is on vacation. The two exceptions for participating in attending rounds are vacation or neurology clinic.
J) Neuroradiology/neuropathology
Site director: Dr. Charles White
Responsible faculty: Pathology: Drs. White, Burns, Hatanpaa, Boyer.
Radiology: Drs. Mendelsohn, Chason, Purdy and Pride
Faculty responsibilities: Pathology: to instruct residents in gross and microscopic neuropathology. Radiology: to instruct residents in reading brain and spine MRI and CT and angiography.
Educational rationale: A focused exposure in these branches of neurologic science will improve the resident?s ability to interpret these investigations.
Duration of exposure: One-month rotation, usually during PGY3.
Policies and Procedures: Daily attendance at noon-time lectures, duty hours policies, disciplinary policies and procedures are outlined in the residency handbook
Educational goals
1. To acquire a working understanding of the technical and procedural aspects of CT, MRI, myelography and angiography
2. To learn to systematically interpret CT, MRI and angiograms, recognizing common appearances of common neurologic problems
3. To read the Greenberg text and self-study the Image MRI program in resident lounge
4. To become familiar with the gross and microscopic pathology correlates of brain, nerve and muscle diseases
5. To read the recommended neuropathology reading list and the Poirier textbook
Service requirements
1. To attend the neuroradiology teaching rounds each morning at 7.30 am
2. To attend at least 10 half-day radiology reading sessions
3. To attend the pathology conferences, brain cuttings and histopathologic reading sessions assigned by the neuropathologist attendings
4. To attend the Tuesday evening muscle-nerve conference and Thursday evening tumor review
