Department of Psychiatry and Human Behavior
Butler Hospital - Rhode Island Hospital – the Miriam Hospital
Revised Date 4/5/2010
Neurology
Overview of Rotation
Neurology rotations in the Brown Psychiatry Residency constitute a core training experience during which residents
learn to perform competent neurological evaluations and treatment of neurological illnesses. The rotation requires a high
degree of organization and efficiency, as well as a strong commitment to professionalism. This latter quality is a core
value, which should guide residents in decision-making about which steps to take on behalf their patients, as well as their
own education.
Description of Rotation
Residents are provided with two months of neurology during their PG1 year. The assignment consists of one-month
rotations at Rhode Island Hospital, Butler Hospital or a neurological outpatient practice under the auspices of the Miriam
Hospital. Each resident’s assignments are scheduled in order to give the resident broad clinical experience in all areas of
neurology.
Butler Hospital: The Neurology Service at Butler Hospital consists of consultations on inpatients and Day Hospital
patients, care of inpatients with neurological disorders on the Behavioral Neurology and Senior Specialty Services and
care of outpatients in the neurology offices of Dr. Salloway and Dr. Rickler.
Rhode Island Hospital: The neurology consultation service at RIH provides a varied intensive exposure to a wide variety
of acute neurologic conditions. Psychiatric residents rotating on neurology are closely supervised by chief residents and
service attendings. The intensive experience gives the resident a strong basis of neurologic experience.
Miriam Hospital: This outpatient neurology rotation gives residents a broad exposure to the assessment and treatment of
common neurologic problems such as headache management, and the management of many neurological illnesses such as
stroke, epilepsy and dementia. There is more exposure to outpatient setting than inpatient setting at Miriam.
I. GENERAL INFORMATION
Neurology
Name of Rotation
James Gilchrist, MD (Rhode Island Hospital),
Chiefs of Service
Norman Gordon, MD (the Miriam Hospital);
Kenneth Rickler MD (Butler Hosptial)
James Gilchrist, MD (Rhode Island Hospital):
Contact Information
Norman Gordon, MD (the Miriam Hospital):
Kenneth Rickler, MD ( Kenneth_Rickler@brown.edu)
Roberta Swanson: (401) 455-6375
Residency Coordinator
II. FACULTY
Drs. Salloway, Wilterdink, Blum, Donnelly, Feldmann, Rizvi, Sachs, Gordon, Rickler. Friedman, Chang, and Weinman
III. TOPICS/TEACHING METHODS/MATERIALS USED DURING THIS ROTATION
Topics to be covered are based upon:
 The patient population cared for by the team over the course of the rotation and
 The weekly afternoon seminars
 Cases selected for presentation
Principal teaching methods:
 Attending Rounds
 Weekly afternoon seminars
Educational materials provided/referred to residents:
 Reading: Each attending and resident is expected to utilize current medical literature in the planning of therapeutic
and diagnostic interventions.
 Computer-assisted educational materials: All housestaff have access to full-text literature search and retrieval
capacity through the hospitals’ computer networks. Terminals are located on all floors and in the residents’ offices.
 Other: Residents are given articles as part of their weekly afternoon seminar series and by faculty on service.
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IV. SPECIFIC AREAS & EXPECTATIONS
Residents are expected to regularly review relevant:
 Neuroimaging studies
 Laboratory testing results
 neuropsychological testing results.
On this rotation, residents may act as consultants to other clinical services such as surgery or psychiatry. Among the
attendings' responsibilities is the application of cost-effective care measures and principles to the actual care of the
patients on the service. Residents are expected to communicate as needed with discharge planning specialists.
V. EVALUATIONS
 Evaluation of the resident's successful completion of the goals listed below will be carried out by the attending.
 Evaluation of the attending's successful completion of the goals listed below will be carried out by the resident.
 Evaluation of the rotation will be completed as part of the annual resident retreat report.
VI. RESPONSIBILITIES OF ATTENDING ON ROTATION
 The ward attending is ultimately responsible for all inpatient care of Neurology Ward Patients.
 The attending will be available to the ward house staff Monday morning through Friday afternoon, 24 hours daily and
on Saturday morning.
 The attending will write admission notes on all patients admitted to the ward service Monday through Friday and
daily progress notes Monday through Saturday.
 The attending will attend rounds each day Monday through Saturday.
 The ward attending is responsible for the clinical education of all housestaff and students rotating on the ward
service. This is generally accomplished by informal as well as formal bedside teaching related to conditions of
patients admitted to the ward service.
 The attending will review all neurological imaging studies with the residents.
 The attending is responsible for monitoring the progress of the resident on rotation throughout the month and
communicating his impressions of the resident's performance to the resident throughout the month.
 The attending will at some time observe each resident in interactions with patients and families, in the performance of
aspects of history taking and physical examination, and will review residents’ admission and progress notes in order
to be able to evaluate the residents’ clinical and communication skills.
 The attending will complete an electronic evaluation for each resident at the end of the month.
VII. RESPONSIBILITY OF RESIDENT ON ROTATION
Rhode Island Hospital:
 The residents on the consult service will evaluate all patients for whom a neurology consultation is requested as
delegated by the chief resident.
 The resident will write a complete consultation note on all patients evaluated and will write regular follow-up notes
on these patients, following up on the patient’s neurologic progress and the results of recommended neurodiagnostic
tests.
 The resident will communicate directly with the primary physician and/or primary housestaff when urgent diagnostic
testing or intervention is required and otherwise as appropriate.
 Residents will attend attending consult rounds each weekday, gather all clinical data required, including xray films,
for complete clinical case presentations to the attending physician.
 In cases requiring immediate attention, the resident will consult with the chief resident and/or attending physician
regarding urgent interventions.
 The residents assigned to the consultation service will work out between themselves an equitable schedule for sharing
the daytime and afternoon/evening assignments.
Butler Hospital:
 Resident is responsible for evaluating inpatient and Day Hospital consultations
 Resident is responsible for assisting Dr. Rickler on Monday, Wednesday, and Thursday, Dr. Weinman on Tuesday,
and Dr. Chang on Friday, with the evaluation and management of selected inpatients on the Behavioral Neurology or
Senior Specialty Services.
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 Residents will see outpatients with Dr. Salloway or Dr. Rickler in their offices
Miriam Hospital:
 Resident will attend regular outpatient hours in Dr. Gordon’s office at 450 Veterans Memorial Parkway in East
Providence
 Resident will perform initial H&P on new patients and present cases to Dr Gordon, with an evaluation and treatment
 Resident will accompany Dr Gordon to the Miriam hospital to consult on inpatients as needed
 Resident will attend Neurology Grand Rounds at RIH on Wednesday mornings from 8 am to 9.30am.
VIII. SCHEDULE DURING THIS ROTATION
Morning Rounds
Monday, Tuesday, Thursday, Friday at 8:00 Neurology Library #322 (RIH)
Noon Resident Conference
Monday, Thursday, Friday Neurology Library #322 (RIH)
Grand Rounds
Wednesday 8am George Auditorium (RIH)
Neuroradiology
Wednesday 12 noon Neuroradiology conference room (RIH)
IX. GENERAL EDUCATIONAL OBJECTIVES
Objectives - By the end of this rotation, the resident will be able to:
Rhode Island Hospital, Miriam Hospital:
 Obtain an orderly and detailed neurologic history, conducting a thorough general and neurological examination, and
organizing and recording data
 Obtain an understanding of the pathophysiology of cerebrovascular disease, its acute management, and diagnostic
evaluation
 Develop the skill set needed to evaluate and manage patients with acute neuromuscular disorders and other inpatient
neurologic disorders including but not limited to seizures, cerebral neoplasms, elevated intracranial pressure, multiple
sclerosis and CNS infections
 Be familiar with the indications for and limitations of clinical neurodiagnostic tests and their interpretation as well as
to correlate the information derived from these neurodiagnostic studies with the clinical history and examination in
formulating a differential diagnosis and management plan
 Prepare and present case presentations
 Develop an appreciation for cost-efficient care, proper utilization of resources, the importance of after-hospital care
planning, and patient autonomy
 Work in a coordinated fashion with a multi-disciplinary team
Additional educational objectives for Butler Hospital:
 Develop careful history taking skills and skills at neuropsychiatric assessment and differential diagnosis
 Better understand brain systems relevant to neurology and psychiatry.
 Be knowledgeable about neurological syndromes affecting psychiatric patients
 Interpret brain CTs and MRIs
X. GOALS AND OBJECTIVES FOR THIS ROTATION – COMPETENCY-BASED
Competency/Description
1. Patient Care
Goals and Objectives
 Resident must be able Residents
Learn to gather essential and accurate information about their patients
to provide care that is
Prepare and present case presentations
compassionate,
Assess severity of illness and demonstrate prioritization skills necessary to
appropriate, and
make interventions in a timely manner
Make informed decisions about diagnostic and therapeutic interventions
effective for the
based on patient information and preferences, up-to-date scientific evidence,
treatment of health
and clinical judgment
problems and the
Counsel family and patients
promotion of health.
Develop the ability to communicate effectively and demonstrate caring and
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2. Medical Knowledge
 Residents must
demonstrate
knowledge about
established and
evolving biomedical,
Evaluation Method
- Residents are evaluated by
their attending
- Performance at morning
report
respectful behaviors when interacting with patients and their families.
Work with health care professionals, including those from other disciplines,
to provide patient-focused care
Goals and Objectives
Residents
Will learn to generate a differential diagnosis and unique treatment plan for
each patient encounter, learn to judiciously use diagnostic tests, laboratory
studies to narrow the diagnosis
Will demonstrate an investigatory and analytic thinking approach to clinical
situations
Learn to effectively communicate their investigatory and analytic thinking
Evaluation Method
- Feedback of both oral and
written presentations will be
provided
- Presentation skills,
management decisions and
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clinical, and cognate
(e.g. epidemiological
and socialbehavioral) sciences
and the application of
this knowledge to
patient care.
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3. Interpersonal and
Communication Skills
 Residents must be
able to demonstrate
interpersonal and
communication skills
that result in effective
information exchange
and teaming with
patients, their
patients’ families,
and professional
associates.
4. Professionalism
 Residents must
demonstrate a
commitment to
carrying out
professional
responsibilities,
adherence to ethical
principles, and
sensitivity to a
diverse patient
population
approach via written notes and at clinical conferences and didactic teaching
sessions
Will keep abreast of new scientific knowledge, which is obtained via
didactic sessions, Grand Rounds, critical review of scientific literature,
computer and web-based resources
Will actively participate in conferences
Understand and apply basic principles of physiology and pathophysiology to
common diseases; understand the diagnosis and prognosis and management
options for these illnesses
Will know and apply the basic and clinically supportive sciences which are
appropriate to their discipline
Goals and Objectives
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Residents will approach patients/families with a friendly, interested, and
respectful demeanor.
Residents will scrupulously maintain patient confidentiality, and specifically
reassure patients/families of the confidentiality of their personal and medical
information
Residents will make every effort to safeguard patient/family dignity.
Residents will know and be able to describe the proper boundaries of the
physician/patient relationship, and will consistently and conscientiously
avoid any breach of these boundaries.
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Residents will make explanations in clear, common-parlance language,
avoiding use of medical jargon, and using graphic aids (including informal
sketches) where helpful to get points across.
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Residents will ask patient’s/family’s concerns and questions and address
these specifically and directly to ensure that patient/family have received
information in the desired degree of detail.
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Residents will clearly identify differences in patient/family and medical
perspectives, bringing such differences into open discussion, and explaining
the rationales for medical actions that differ from patient/family preferences
and values.
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Residents will negotiate priorities for problems to be addressed in the
particular visit, once all issues have been identified.
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Residents will write clearly and legibly when hand-writing instructions or
other information for patients/families
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Residents will help to ensure that written or printed information for
patients/families is language-congruent and literacy appropriate using
straightforward language and comprehensible and culturally appropriate
illustration.
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Written communications in patient charts will effectively permit subsequent
caregivers to understand the nature of the patient interaction and the goals
and plans for the encounter as well as future encounters when applicable
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Residents will ask patients/family members how they wish to be addressed
Residents will openly support and assist patients/families in dealing with
health challenges and their administrative complications.
Residents will know and avoid breach of the boundaries of the
physician/patient relationship, including but not limited to strict avoidance
of sexual or romantic suggestiveness or involvement with patients/family
members.
Residents will make reasonable efforts to act as advocates for their patients.
Residents will place patient safety as their first priority without
compromising their own safety or the safety of others that they are
supervising.
Residents will recognize and support patient’s rights to receive full
information regarding the risks, benefits, and when appropriate, costs of
appropriate treatment options, and to be advised of potential conflicts of
interest on the part of their physicians.
Residents will truthfully report medical errors of their own to their
attending, or Risk Management and to follow hospital protocols in the face
of errors. Residents will encourage and facilitate reporting of medical error
on the part of professional colleagues.
Residents will seek professional help for personal impairments that may
Goals and Objectives
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knowledge are evaluated at
morning rounds
Evaluation Method
- Attendings rate their residents
on rounds, bedside teaching
interactions
- Observation by chiefs, other
residents on a day to day basis
- Feedback from nursing staff,
other disciplines
Evaluation Method
- Residents evaluate each other
each month and rate their
interpersonal skills with each
member of the team as well as
with patients/families
- Attendings rate their team on
rounds, bedside teaching
interactions
- Observation by chiefs, other
residents on a day to day basis
- Feedback from nursing staff,
other disciplines
- Patient satisfaction surveys
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Residents will participate with an attitude to support the appropriate
decisions of patients or recognized family decision makers to withhold or
withdraw life-sustaining treatment from patients in terminal conditions.
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Residents will fully and clearly inform patients and families of the benefits
and risks of all proposed diagnostic and therapeutic interventions, with the
purpose of facilitating the ability to make an informed decision, even if the
eventual decision is not the one the physician prefers for the patient.
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Residents will avoid any form of coercion of patient/family decision
making.
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Residents will make every effort to elicit and to accommodate, to the fullest
extent of their ability, differing religious and cultural needs and values in
delivering medical care– but are under no obligation to accommodate
requests based upon any form of identity-group prejudice.
Residents will clearly and openly identify and repudiate statements of
prejudice made by professional colleagues, and will not permit their actions
as physicians to be influenced by such prejudice.
Residents will cultivate the ability to identify and articulate their own
cultural values and preferences, comforts and discomforts; and to be self
aware in attempting to deliver fair and optimal medical care to all patients –
including recognizing their obligation to transfer care to another physician
should the occasion arise in which personal values or biases interfere with
such care delivery to any patient or family.
Demonstrate understanding of and sensitivity to end of life care and issues
regarding provision of care.
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5. Practice-Based
Learning and
Improvement
 Residents must be
able to investigate
and evaluate their
patient care practices,
appraise and
assimilate scientific
evidence, and
improve their patient
care practices.
Goals and Objectives
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6. Systems-Based
Practice
 Resident must
demonstrate an
awareness of and
responsiveness to a
larger context and
system of health care
and the ability to
effectively call on
compromise patient care; will assist impaired colleagues to obtain
professional help; and will take responsibility for interceding to protect
patient safety when impaired colleagues do not respond appropriately to
their own duties in this regard.
Residents shall not withhold needed medical care from patients/families
wishing to receive it, irrespective of ability to pay for such care.
At the end of this rotation, the resident should be able to identify gaps in
knowledge based upon experience, introspective awareness, and feedback
for the month. The resident is expected to regularly review both textbook
and primary source literature to maintain up to date understanding of
specific topics that have arisen in practice.
The resident should actively seek feedback and advice on practice from
peers, mentors, staff, and patients alike to gain greater objective insight into
their strengths and weaknesses.
The resident should be able to obtain scientific literature, appraise quality,
and assimilate data through the use of up to date resources to improve their
practice and care of patients’ health problems.
The resident will gain basic skills in literature search methodologies using
standard web-based medical literature search engines such as Ovid, MD
Consult, Pubmed.
The resident will have familiarity with a variety of computer and hand-held
computer based resources for looking up medications, dosing, and other
topics of use to the general internist
The resident will actively participate in lectures and discussions with peers
and experts on the topics related to the care of their patients.
The resident is expected to take a proactive and interactive approach to
enhancing their knowledge. The resident is expected to “think out loud”,
ask for clarification and guidance, and actively seek input on their practice
and knowledge base from their mentors.
Goals and Objectives
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The resident will learn how to work within a multidisciplinary team to
develop a care plan for their patients.
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The resident will become familiar with hospital and community based
health care professionals and their roles in groups such as social work,
mental health professionals, PT, OT, dietitians, and VNA etc.
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The resident will evaluate how interacting with the above groups and health
professionals affects their own practice..
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The resident will practice cost-effective health care and resource allocation
Evaluation Method
- Day to day knowledge base
evaluated by feedback on
differential diagnoses,
management plans
-morning rounds
-conferences
Evaluation Method
- Evaluations from attending
- Feedback from team
members
- Observation by chiefs and
other faculty
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system resources to
provide care that is of
optimal value. By
the end of their
training, residents are
expected to have
attained competence
in the following
goals.
that does not compromise quality of care.
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The resident will learn about a variety of insurances and how they affect
patient referrals and prescriptions. They will learn the legal rights of the
uninsured and will work with the appropriate services to assist patients who
are under- or un-insured.
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The resident will learn how to interact and advocate effectively with other
physicians, ancillary caregivers, community agencies, landlords, and
insurance companies etc. via spoken and written communications when it
effects the health of their patients.
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The resident will learn about the various community resources available for
patients and will work with case managers and social workers to enable
patients to access these resources. The resident will learn to work with
translator services for optimal and appropriate patient care
XI. OTHER IMPORTANT INFORMATION FOR RESIDENT DURING THIS ROTATION
Residents should be mindful of the unique opportunity with which they are presented during this rotation. In caring for sick,
hospitalized patients in a supervised environment, you are being given the chance to study in a protected environment while caring for
patients with the illnesses you are studying. We urge you not to waste this time but rather to embrace your responsibilities and to
study and teach based upon the needs of your patients.
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